There were more than 574,000 primary lower limb total joint arthroplasties performed in the United States in 2002 and 48,000 in Canada over approximately the same period. The incidence of clinically apparent myocardial infarction following lower limb arthroplasty has been previously reported at 1.8% (Gandhi et al, 2006). The functional outcome of patients suffering post-operative myocardial infarctions has never been reported to our knowledge. Our hypothesis is that functional scores of patients undergoing total joint arthroplasty that suffer peri-operative myocardial infarction will be lower than in our control patients. Patients were retrospectively identified from a prospectively collected database of total joint arthroplasties performed at one center. Six surgeons performed 3320 primary lower limb arthroplasties over a period of seven years. Patients of interest were identified via discharge summaries to have suffered a myocardial infarction diagnosed clinically and confirmed by biochemical assay. These patients were then case matched for demographics, risk factors and pre-operative functional score. Sixty-two patients (twenty six hips and thirty six knees) were identified as having suffered a post-operative myocardial infarction. There was an overall mortality of 13% and only thirty-four of the sixty-two (55%) completed follow-up to one year. The clinical course of the remaining patients remains uncertain. Statistically significant differences have been observed in Oxford hip scores at six weeks post operatively. Any differences disappear by six months. No statistically significant differences in outcomes were seen in knee outcomes. It would appear that those patients who are well enough to return for follow-up do just as well as those patients who did not suffer myocardial infarctions. There may be some differences in the rate of recovery from the surgery, but it appears that overall functional outcome of the patients that survive remain good

Retrospective review of four thousand two hundred and fifty-two patients undergoing TJR at a single high-volume arthroplasty centre to determine prevalence and timing of myocardial infarction (MI) following TJR. The incidence of peri-operative MI was 1.5%, with a mean of three days to time of MI. This cohort was comprised of 55% females with a mean age of seventy-five years. We found poor correlation between pre-operative risk assessment using the Modified Multifactorial Index score. Our findings suggest that there is a minimum length of stay compatible with patient safety given the inadequacy of currently available preoperative risk assessment tools. This study was undertaken to evaluate the prevalence and timing of peri-operative myocardial infarction in patients undergoing total joint replacement (TJR). Despite the pressure toward decreasing length of stay following TJR surgery, we suggest that there is a minimum length of stay compatible with patient safety given the inadequacy of currently available preoperative risk assessment tools. The prevalence rate of peri-operative MI was 63/4252(1.5%), with a mean time of three days (range 0–18) to MI. Furthermore, there was a predominance of females (55%) and a mean age of seventy-five years among this cohort. We found poor correlation between pre-operative risk assessment using the Modified Multifactorial Index score. Patients who suffered an acute MI following elective TJR surgery between April 1998 and April 2003 were abstracted from the Hospital CIHI database of four thousand two hundred and fifty-two patients. The role of preoperative risk assessment and risk reduction strategies were also evaluated. The previously reported rate of MI is 0.3 % and 0.9% following unilateral and bilateral TJR respectively. The reported frequency of MI tends to increase with older age (> 70 yrs) and male gender. There is emerging information that these rates may be grossly under-estimated. Prosthetic arthroplasty is major surgery and regardless of the surgical technique, patients remain at risk for complications

The mortality following surgery in patients with a recent MI is high. Standard advice is to wait for a minimum of 6 months. In urgent situations, this may not be possible. From Jan 2003 to Aug 2004, 10 patients were admitted with fracture neck of femur and a recent MI proven by ECG changes or raised troponin. There were 7 females. The mean age was 79.5 yrs (59–95yrs). The premorbid mobility and co-morbidities were noted. Echocardiography was done in all patients preoperatively to assess the cardiac function. All patients were seen by physicians and anaesthetist pre-operatively. The mean time from infarction to operation was 11.5 days (3–23 days). The patients underwent either Thompsons hemiarthroplasty or DHS. The anaesthetic was performed by a consultant. Most patients received spinal anaesthesia (7/9). The anaesthetic records could not be found for 1 patient. 6 patients died within a month and 1 patient died within 6 month of operation. Despite thorough preoperative work-up and consultant anaesthesia, the mortality following surgery for proximal femur fractures in patients with recent myocardial infarction is 70% at 6 months. To our knowledge, there are no published mortality figures for this situation. This is much higher than the reported mortality following proximal femur fracture

We examined the risk of thrombotic and major bleeding events in patients undergoing total hip and knee replacement (THR and TKR) treated with thromboprophylaxis, using nationwide population-based databases. We identified 83 756 primary procedures performed between 1997 and 2011. The outcomes were symptomatic venous thromboembolism (VTE), myocardial infarction (MI), stroke, death and major bleeding requiring hospitalisation within 90 days of surgery. A total of 1114 (1.3%) and 483 (0.6%) patients experienced VTE and bleeding, respectively. The annual risk of VTE varied between 0.9% and 1.6%, and of bleeding between 0.4% and 0.8%. The risk of VTE and bleeding was unchanged over a 15-year period. A total of 0.7% of patients died within 90 days, with a decrease from 1% in 1997 to 0.6% in 2011 (p < 0.001). A high level of comorbidity and general anaesthesia were strong risk factors for both VTE and bleeding, with no difference between THR and TKR patients. The risk of both MI and stroke was 0.5%, which remained unchanged during the study period. . In this cohort study of patients undergoing THR and TKR patients in routine clinical practice, approximately 3% experienced VTE, MI, stroke or bleeding. These risks did not decline during the 15-year study period, but the risk of dying fell substantially. Cite this article: Bone Joint J 2014;96-B:479–85

Aims. To compare rates of serious adverse events in patients undergoing revision knee arthroplasty with consideration of the indication for revision (urgent versus elective indications), and compare these with primary arthroplasty and re-revision arthroplasty. Methods. Patients undergoing primary knee arthroplasty were identified in the national Hospital Episode Statistics (HES) between 1 April 1997 to 31 March 2017. Subsequent revision and re-revision arthroplasty procedures in the same patients and same knee were identified. The primary outcome was 90-day mortality and a logistic regression model was used to investigate factors associated with 90-day mortality and secondary adverse outcomes, including infection (undergoing surgery), pulmonary embolism, myocardial infarction, and stroke. Urgent indications for revision arthroplasty were defined as infection or fracture, and all other indications (e.g. loosening, instability, wear) were included in the elective indications cohort. Results. A total of 939,021 primary knee arthroplasty procedures were included (939,021 patients), of which 40,854 underwent subsequent revision arthroplasty, and 9,100 underwent re-revision arthroplasty. Revision surgery for elective indications was associated with a 90-day rate of mortality of 0.44% (135/30,826; 95% confidence interval (CI) 0.37 to 0.52) which was comparable to primary knee arthroplasty (0.46%; 4,292/939,021; 95% CI 0.44 to 0.47). Revision arthroplasty for infection was associated with a much higher mortality of 2.04% (184/9037; 95% CI 1.75 to 2.35; odds ratio (OR) 3.54; 95% CI 2.81 to 4.46), as was revision for periprosthetic fracture at 5.25% (52/991; 95% CI 3.94 to 6.82; OR 6.23; 95% CI 4.39 to 8.85). Higher rates of pulmonary embolism, myocardial infarction, and stroke were also observed in the infection and fracture cohort. Conclusion. Patients undergoing revision arthroplasty for urgent indications (infection or fracture) are at higher risk of mortality and serious adverse events in comparison to primary knee arthroplasty and revision arthroplasty for elective indications. These findings will be important for patient consent and shared decision-making and should inform service design for this patient cohort. Cite this article: Bone Joint J 2021;103-B(10):1578–1585

Revision knee arthroplasty is a complex procedure with the number and cost of knee revision procedures performed per year expected to rise. Few studies have examined adverse events following revision arthroplasty. The objective of this study was to determine rates of serious adverse events in patients undergoing revision knee arthroplasty with consideration of the indication for revision (urgent versus elective indications) and to compare these with primary arthroplasty and re-revision arthroplasty. Patients undergoing primary knee arthroplasty were identified in the UK Hospital Episode Statistics. Subsequent revision and re-revision arthroplasty procedures in the same patients and same knee were identified. The primary outcome was 90-day mortality and a logistic regression model was used to investigate factors associated with 90-day mortality and secondary adverse outcomes including infection (undergoing surgery), pulmonary embolism, myocardial infarction, stroke. Urgent indications for revision arthroplasty were defined as infection or fracture, and all other indications were included in the elective indications cohort. 939,021 primary knee arthroplasty cases were included of which 40,854 underwent subsequent revision arthroplasty, and 9,100 underwent re-revision arthroplasty. Revision surgery for elective indications was associated with a 90-day rate of mortality of 0.44% (135/30,826; 95% CI 0.37-0.52) which was comparable to primary knee arthroplasty (0.46%; 4,292/939,021; 95% CI 0.44-0.47). Revision arthroplasty for infection, however, was associated with a much higher mortality of 2.04% (184/9037; 95% CI 1.75-2.35; odds ratio [OR] 3.54; 95% CI 2.81-4.46), as was revision for periprosthetic fracture at 5.25% (52/991; 95% CI 3.94-6.82; OR 6.23; 95% CI 4.39-8.85). Higher rates of pulmonary embolism, myocardial infarction, and stroke were also observed in the infection and fracture cohort. These findings highlight the burden of complications associated with revision knee arthroplasty. They will inform shared decision-making for patients considering revision knee arthroplasty for elective indications. Patients presenting with infection of a knee arthroplasty or a periprosthetic fracture are at very high risk of adverse events. It is important that acute hospital services and tertiary referral centres caring for these patients are appropriately supported to ensure appropriate urgency and an anticipation for increased care requirements

The National Institute for Clinical Excellence, UK published guidelines in 2007 encouraging the use of low molecular weight heparin (LMWH) joint replacement surgery. Subsequently, our hospital adopted these guidelines in the treatment of total hip replacements. This study is based on our prospective database of total hip replacements between 2005 and 2009 and compares the complication and mortality rates pre- and post institution of the NICE guidelines. We analysed prospectively collected data on 686 patients who underwent a primary total hip replacement done by a single surgeon between January 2005 and April 2009. We compared the incidence of mortality, pulmonary embolism, myocardial infarction and intracranial bleeding between the two groups. Prior to the guidelines, all patients were treated for the duration of their admission with 75mg aspirin followed by 4 weeks after discharge. Subsequent to the guidelines, the treatment changed to 40mg of LMWH (Clexane) while an inpatient with aspirin being prescribed for 4 weeks on discharge. Patients unable to tolerate aspirin were treated with low molecular weight heparin. High risk patients (previous pulmonary embolism, previous deep vein thrombosis, family history) were treated with 6 weeks of warfarin. Each patients was reviewed at 8 weeks and 6 months following surgery, and adverse incidents were documented at each review or incident. Results: 686 patients were identified from the study – 328 pre and 358 post implementation of the NICE guidelines. In the pre-guideline group the mortality was 0.6%, with the incidence of pulmonary embolism being 0.3%, myocardial infarction 0.9% and intracranial bleed 0.3%. Both complications of myocardial infarction occurred early in the post-operative stage and were fatal. The post-guideline group had a mortality rate of 0.2%, with the incidence of pulmonary embolism being 0.2% and intracranial bleeding 0.2%. No myocardial infarctions were noted in this group. The single death was as a result of an intracranial bleed. The was no significant statistical difference in the incidence of mortality, pulmonary embolism, myocardial infarction or intracranial bleeding between the two groups (p value > 0.05, 95% confidence interval). There were no complications in the warfarinised patients of which there were equal numbers in both groups (16). Conclusion: This study has shown that the change in thromboprophylaxis has not had a significant effect on complication rates in primary total hip replacements and that our mortality rate (0.4%) compares favourably with recent literature. The lack of complications in the war-farinised group probably reflects that high risk patients were identified in the screening process and commenced on warfarin early in the post operative period. Note must be made of the single death due to an intracranial bleed while on low molecular weight heparin

Aims. Our main aim was to describe the trend in the comorbidities of patients undergoing elective total hip arthroplasties (THAs) and knee arthroplasties (KAs) between 1 January 2005 and 31 December 2018 in England. Methods. We combined data from the National Joint Registry (NJR) on primary elective hip and knee arthroplasties performed between 2005 and 2018 with pre-existing conditions recorded at the time of their primary operation from Hospital Episodes Statistics. We described the temporal trend in the number of comorbidities identified using the Charlson Comorbidity Index, and how this varied by age, sex, American Society of Anesthesiologists (ASA) grade, index of multiple deprivation, and type of KA. Results. We included 696,504 and 833,745 elective primary THAs and KAs respectively, performed for any indication. Between 2005 and 2018, the proportion of elective THA and KA patients with one or more comorbidity at the time of their operation increased substantially (THA: 20% to 38%, KA: 22% to 41%). This was driven by increases in four conditions: chronic obstructive pulmonary disease (COPD) (2018: ~17%), diabetes without complications (2018: THA 10%, KA 14%), myocardial infarction (2018: 4%), and renal disease (2018: ~8%). Notably, renal disease prevalence increased from < 1% in 2005 to ~8% in 2018. Conclusion. Between 2005 and 2018 there were significant changes in the number of comorbidities recorded in patients having elective primary THAs and KAs. Renal disease is now one of the most prevalent comorbidities in this patient population. Future research should explore whether this comorbidity trend has increased the burden on other medical specialities to optimize these patients before surgery and to provide additional postoperative care. Cite this article: Bone Joint J 2022;104-B(9):1052–1059

Prior to TJR, clinical cardiovascular risk assessment is typically limited by severe exercise restrictions. Noninvasive pharmacological cardiovascular stress tests may predict major perioperative cardiovascular events in patients undergoing orthopaedic surgery. We undertook a pilot study to inform the feasibility of a large prospective cohort study. Patients were eligible if they were aged > forty-five, undergoing elective TJR, and had known atherosclerotic disease or risk factors for atherosclerotic disease. We recruited patients at the Hamilton Health Sciences, Henderson Hospital. Prior to surgery patients underwent dipyridamole stress perfusion imaging and dobutamine stress echocardiography. For both tests the interpreters evaluated seventeen myocardial segments and were blinded to information about patients’ clinical risk factors. The attending surgeons and research personnel following patients after surgery were blinded to results of the noninvasive pharmacological cardiovascular stress tests. All patients had an ECG performed and troponin T drawn six to twelve hours postoperatively and on the first, second and third days after surgery. Starting in November 2005 we recruited thirty patients over six months; seventeen (57%) patients were male, twenty-one (70%) underwent TKA, and nine (30%) underwent THA. The length of surgery was seventy-two (SD 38) minutes and the length of hospital stay was five (SD 3) days. We successfully followed all patients to thirty days after surgery. Three patients (10%; 95% CI, 3–26%) suffered a perioperative myocardial infarction. Twenty nine patients underwent dipyridamole stress perfusion imaging prior to surgery; a reversible defect involving 30–50% of the myocardium increased the likelihood of a perioperative myocardial infarction (likelihood ratio [LR] 4.0; 95% CI, 1.2–13.3). Twenty-six patients underwent dobutamine stress echo-cardiography; a reversible defect increased the likelihood of a perioperative myocardial infarction (LR 4.0; 95% CI, 0.7–22.9). This pilot study demonstrates the need for, and feasibility of, a large prospective cohort study to determine if preoperative noninvasive pharmacological cardiovascular stress testing has additional predictive value, beyond clinical variables, for the occurrence of myocardial infarction in patients undergoing major hip and knee surgery

Aims. As our population ages, the number of octogenarians who will require a total hip arthroplasty (THA) rises. In a value-based system where operative outcomes are linked to hospital payments, it is necessary to assess the outcomes in this population. The purpose of this study was to compare outcomes of elective, primary THA in patients ≥ 80 years old to those aged < 80. Methods. A retrospective review of 10,251 consecutive THA cases from 2011 to 2019 was conducted. Patient-reported outcome (PRO) scores (Hip disability and Osteoarthritis Outcome Score (HOOS)), as well as demographic, readmission, and complication data, were collected. Results. On average, the younger cohort (YC, n = 10,251) was a mean 61.60 years old (SD 10.71), while the older cohort (OC, n = 609) was 84.25 years old (SD 3.02) (p < 0.001). The OC had greater surgical risk based on their higher mean American Society of Anesthesiologists (ASA) scores (2.74 (SD 0.63) vs 2.30 (SD 0.63); p < 0.001) and Charlson Comorbidity Index (CCI) scores (6.26 (SD 1.71) vs 3.87 (SD 1.98); p < 0.001). While the OC stayed in the hospital longer than the YC (mean 3.5 vs 2.5 days; p < 0.001), there were no differences in 90-day emergency visits (p = 0.083), myocardial infarctions (p = 0.993), periprosthetic joint infections (p = 0.214), dislocations (p = 0.993), or aseptic failure (p = 0.993). The YC was more likely to be readmitted within 90 days (3.88% vs 2.18%, Β = 0.57; p = 0.048). There were no observed differences in 12-week (p = 0.518) or one-year (p = 0.511) HOOS scores. Conclusion. Although patients ≥ 80 years old have a greater number of comorbidities than younger patients, they had equivalent perioperative complication rates and PRO scores. This study demonstrates the safety and success of elective THA in octogenarians. Cite this article: Bone Jt Open 2021;2(7):535–539

Aims. The impact of tobacco use on readmission and medical and surgical complications has been documented in hip and knee arthroplasty. However, there remains little information about the effect of smoking on the outcome after total shoulder arthroplasty (TSA). We hypothesized that active smokers are at an increased risk of poor medical and surgial outcomes after TSA. Methods. Data for patients who underwent arthroplasty of the shoulder in the USA between January 2011 and December 2015 were obtained from the National Readmission Database, and 90-day readmissions and complications were documented using validated coding methods. Multivariate regression analysis was performed to quantify the risk of smoking on the outcome after TSA, while controlling for patient demographics, comorbidities, and hospital-level confounding factors. Results. A total of 196,325 non-smokers (93.1%) and 14,461 smokers (6.9%) underwent TSA during the five-year study period. Smokers had significantly increased rates of 30- and 90-day readmission (p = 0.025 and 0.001, respectively), revision within 90 days (p < 0.001), infection (p < 0.001), wound complications (p < 0.001), and instability of the prosthesis (p < 0.001). They were also at significantly greater risk of suffering from pneumonia (p < 0.001), sepsis (p = 0.001), and myocardial infarction (p < 0.001), postoperatively. Conclusion. Smokers have an increased risk of readmission and medical and surgical complications after TSA. These risks are similar to those found for smokers after hip and knee arthroplasty. Many surgeons choose to avoid these elective procedures in patients who smoke. The increased risks should be considered when counselling patients who smoke before undertaking TSA. Cite this article: Bone Joint J 2020;102-B(11):1549–1554

The growth of life expectancy during the last decades has led to an increment in age-related conditions such as hip arthritis and fractures. On the other hand, these elderly patients will present a higher incidence of mental diseases which, in some studies, have been associated with inferior results. This study aims to evaluate the differences in early complication rates between patients with cognitive impairment compared with those without this condition following total hip replacement for osteoarthritis or fracture in the context of contemporary perioperative care protocols. We conducted a retrospective cohort study where cognitively-impaired patients who required primary hip arthroplasty were compared to a propensity-score matched cohort of patients without cognitive alterations. Early major complications were measured and analyzed in order to determine significant differences. Screening and matching. 1196 patients were identified during the study period. After screening for inclusion and exclusion criteria and matching, two cohorts comprising 65 patients each were compared. After performing the propensity-score match, no significant differences were found in covariates between the two groups. Outcomes. The occurrence of delirium was more frequent in patients with cognitive deficit (27.5%) than in the control group (9%), p<0.001. No significant differences were found among groups regarding myocardial infarction, venous thromboembolism, blood transfusion requirement, 30-day readmission, in-hospital death, 90-days death, dislocation or surgical site infection. The composite outcome of any adverse event did not exhibit a significant difference either. To our knowledge, this is the first study which demonstrates similar outcomes between patients with cognitive impairment and those without these alterations. Our results might indicate that contemporary protocols and implants are bridging the traditional gap between these two populations. These findings support the use of total hip arthroplasty in patients with mental alterations when indicated, especially in those institutions with strict perioperative protocols

Abstract. Introduction. The demand for total knee arthroplasty (TKA) in older patients is increasing. Current perceptions regarding risks may result in patients inappropriately being denied surgery. This study aimed to evaluate TKA outcomes in patients aged ≥80 compared to a younger cohort. Methodology. This study retrospectively analysed prospectively collected data from the Scottish Arthroplasty Project. Data were extracted for all patients undergoing primary TKA between 2000 and 2019 in two age groups: 1) ≥80 and 2) 50–79. Hybrid and partial knee replacements and those with incomplete data were excluded. Data were extracted on post-operative complications, infection within 1 year, mortality and revision at any point. Results. In patients aged ≥80, rates of post-operative myocardial infarction, acute kidney injury, venous thromboembolism and pulmonary embolism were 0.8%, 2.2%, 0.4% and 0.9% respectively. Rates in the 50–79 group were 0.3%, 0.9%, 0.3% and 0.7%. Infection was comparable in both groups (1.3% in ≥80 vs 1.1% in 50–79). Patients ≥ 80 survived mean 6.4 years following TKA compared to 8.4 years for patients aged 50–79. Revision rates were higher in those aged 50–79 (3.2%) compared to ≥80 (1.1%). Revision surgery did not adversely affect mortality in the ≥80ies. After revision, patients survived a mean 7.4 years compared to 6.3 years for those who did not undergo revision. Conclusion. Over the past 20 years, 11.4% of TKAs performed in Scotland have been in patients aged ≥80. These data show that complication rates are comparable to younger patients and age alone should not be a barrier to TKA

There is an increasing demand worldwide for total hip arthroplasty in patients over 80 years old. This study is the largest of its kind reporting long term outcomes and clinical survivorship of patients over 80 years old undergoing THR. 13171 patients 80 years or older who underwent THR between 2000 and 2019 were included. Demographic and operative data was collected including age, sex, laterality, date of surgery and operative technique. Presence and date of complications were collected. Data was also collected for the same time period on 80910 patients aged 51–79 years undergoing THR for comparison. 4103 (31.2%) male and 9068 female (68.8%) patients were included in the 80year old cohort. Median age was 83 (IQR 81–83, range 80–98). 32682 (40.4%) male and 48227 (59.6%) females were included in the 50–79year old cohort. Median age was 68 (IQR 62–73, range 50–79). The 80 cohort was more likely to sustain post operative complications in the 6 months following surgery including DVT (81/13171 vs 364/80910, P<0.05), myocardial infarction (177/13171 vs 341/80910, P<0.05), acute renal failure (371/12800 vs 812/80910 P<0.05). The 50–79year old cohort was over twice as likely to undergo revision surgery than the 80 year old cohort (HR 2.55, 95% CI 2.216–2.932, p<0.001). Of those requiring revision surgery, the elderly cohort were more likely to undergo earlier revision surgery (378days, 95%CI 236–519d vs 1586days, 95%CI 1471–1700d, p<0.001). In those undergoing revision surgery, a higher proportion were done for infection in the 80 year old cohort (39/219 (17.8%) vs 215/2809 (7.7%), p<0.05. This study demonstrates good outcomes in terms of medical complications and a low overall risk of requiring revision surgery in patients 80years old undergoing THR. Patients over the age of 80 should be counselled on the relatively increased risk of medical complications post operatively

We aimed to use data from a randomized controlled trial (RCT) comparing the sliding hip screw vs. intramedullary nailing (IMN) for trochanteric fractures to examine complication rates between those managed with a short vs. long IMN. This is a secondary analysis using one arm of an RCT of patients ≥18 years with trochanteric fractures. We examined differences in fracture-related (femoral shaft fracture, implant failure, surgical site infection (SSI), nonunion, limb shortening, and pain) and medical (organ failure, respiratory distress, stroke, deep vein thrombosis [DVT] gastrointestinal upset, pneumonia, myocardial infarction, sepsis, or urinary tract infection) adverse events (AE), and readmission between short vs. long IMNs. We included 412 trochanteric fracture patients, 339 (82.2%) of whom received a short (170mm–200mm) nail, while 73 (17.7%) received a long (260mm–460 mm) nail. Patients in the long group were more likely to be admitted from home (vs. an institution), and have comorbidities, or more complex fracture types. Patients in the long group had higher rates of fracture-related AE (12.3%) vs. the short group (3.5%). Specifically, SSI (5.5% vs. 0.3%) and pain (2.7% vs. 0.0%) were significantly higher in the long group. Patients in the long group were also more likely to develop DVT (2.7% vs. 0.3%), and be readmitted to the hospital (28.8% vs. 20.7%). Following covariable adjustment, long nails remained associated with a higher odds of fracture-related AE (5.11, 1.96–13.33) compared to short nails. We found no association between the adjusted odds of readmission and nail length (1.00, 0.52–1.94). Our analyses revealed that trochanteric fracture patients managed with long IMN nails may have a higher odds of fracture-related AE compared to short nails. Future research is required to validate these findings with larger event rates, and further optimize IMN for trochanteric fracture patients

Debate continues about the best treatment for patients over 65 years with non-displaced subcapital hip fractures: internal fixation (IF) or hemiarthroplasty (HA). Surgical aggression, mortality, complications and recovery of walking ability after 1year have been compared between both treatments. Match-paired comparison of 2 retrospective cohorts. 220 patients with IF vs 220 receiving a cemented bipolar HA. Matching by age (82.6±7.16 years (65–99)), sex (74.5% women), year of intervention (2013–2021) and ASA scale (24.2% ASA II, 55.8% III, 20.0% IV). Age (p=0.172), sex (p=0.912), year of intervention (p=0.638) and ASA scale (p=0.726) showed no differences. Surgical aggression smaller in IF: Surgical time (p< 0,00001), haemoglobin/haematocrit loss (p <0,00001), need for transfusion (p<0,00008), in-hospital stay (p<0,00001). Mortality: higher in-hospital for hemiarthroplasties (12 deaths (5.5%) vs 1 (0.5%) (p=0.004) (RR=12, 1.5–91.5)). But no significant differences in 1-month (13 hemiarthroplasties, 6%, vs 9 osteosynthesis, 4.1%) and 1-year mortality (33 hemiarthroplasties, 15%, vs 35, 16%). Medical complications: no differences in urinary/respiratory infections, heart failure, ictus, myocardial infarction, digestive bleeding, pressure sores or pulmonary embolus (p=0.055). Surgical complications: no significant differences. HA: 6 intraoperative (2,7%) and 5 postoperative periprosthetic fractures (2,3%), 5 infections (2,3%), 10 dislocations (4,5%), 3 neurovascular injuries. IF: 10 acute fixation failures (4,5%), 2 infections (0,9%), 9 non-unions (4,1%), 16 ischemic necrosis (7,3%). Functional results: no significant differences; 12 patients in each group (5,5%) never walked again (p=1), 110 HA (50%) and 100 IF (45.5%) suffered worsening of previous walking ability (p=0.575), 98 HA (44%) and 108 IF patients (49%) returned to pre-fracture walking ability (p=0.339). Fixation with cannulated screws may be a better option for non-displaced femoral neck fractures because recovery of walking ability and complications are similar, while surgical aggression and in-hospital mortality are lower

Aim. Perioperative myocardial infarction/injury (PMI) is a common complication in noncardiac surgery, contributing to postoperative morbidity and mortality. We aimed to identify the risk for PMI in periprosthetic joint infection (PJI) in comparison to primary hip (THA) and knee arthroplasty (TKA) and to non-PJI revision surgery. Methods. Patients undergoing primary/revision THA/TKA at a University Hospital who were eligible for the institutional PMI screening and response program were prospectively included. Revision arthroplasties were divided into 2 groups (PJI revision and non-PJI revision). PJI was defined according to the EBJIS criteria, and included DAIR, one-stage and two-stage revisions. Non-PJI revisions included partial and/or complete exchange of components. The primary endpoint was PMI, secondary endpoints were major adverse cardiovascular events (MACE) and all-cause mortality within 120 days. Results. The study population included 673 patients (443 primary THA/TKA, 119 PJI revision, 111 Non-PJI revision) enrolled from 05/2014 to 06/2018. The median age in all groups was 75 years. In primary, non-PJI and PJI revision surgery, 39%, 41% and 50%, respectively were male. PMI occurred in 12% of patients with primary arthroplasty compared to 20% and 35% in non-PJI and PJI revision, respectively (p<0.001 overall), with PJI having a significantly elevated risk over non-PJI revisions (p=0.014). Conversely, in MACE (4% primary vs 9% non-PJI vs 12% PJI, p=0.002) an all-cause mortality (2% primary vs 4% non-PJI vs 9% PJI, p<0.001) no significant difference between PJI and non-PJI revisions was observed. We found no difference for the risk of PMI comparing DAIR vs one-/two-stage PJI revision (p=0.88). In multivariable analysis (primary arthroplasty as reference), significant odds ratios for PMI included PJI (3, 1.7–5.3), coronary artery disease (2.9, 1.9–4.4), chronic heart faiure (1.3, 1.1–1.7) and age (1.1, 1.0–1.1 per each year age). Urgency of surgery, duration of surgery, to the presence of Staphylococcus aureus were not significant. impact on PMI. Conclusion. In PJI, PMI and MACE were 3-times, and death 4.5 times, respectively, more frequently observed than in primary arthroplasty. Also, PJI had the highest odds for PMI (3.0). Orthopaedic surgeons should be aware of the high PMI risk when performing revision surgery. This work confirms the importance of a peri-/postpoperative PMI screening and response program in the field of septic surgery

Aims. Many case reports and small studies have suggested that cobalt ions are a potential cause of cardiac complications, specifically cardiomyopathy, after metal-on-metal (MoM) total hip arthroplasty (THA). The impact of metal ions on the incidence of cardiac disease after MoM THA has not been evaluated in large studies. The aim of this study was to compare the rate of onset of new cardiac symptoms in patients who have undergone MoM THA with those who have undergone metal-on-polyethylene (MoP) THA. Patients and Methods. Data were extracted from the Standard Analytics Files database for patients who underwent MoM THA between 2005 and 2012. Bearing surface was selected using International Classification of Diseases ninth revision codes. Patients with a minimum five-year follow-up were selected. An age and gender-matched cohort of patients who underwent MoP THA served as a comparison group. New diagnoses of cardiac disease were collected during the follow-up period. Comorbidities and demographics were identified and routine descriptive statistics were used. Results. We identified 29 483 patients who underwent MoM THA and 24 175 matched patients who underwent MoP THA. Both groups had a mean Charlson comorbidity index score of 4. There were no statistically significant differences in 30 of 31 pre-existing comorbidities. Patients undergoing MoM THA had a slightly lower incidence of cardiac failure compared with those undergoing MoP THA at three years (6.60% versus 7.06%, odds ratio (OR) 0.93, 95% confidence interval (CI) 0.87 to 0.99) and four years (8.73% versus 9.49%, OR 0.91, 95% CI 0.86 to 0.97) postoperatively, with no difference in the incidence of new cardiac failure in between the groups at five years. There was no statistically significant difference in the incidence of arrhythmia, myocardial infarction and cardiomyopathy at any time between the two groups. Conclusion. MoM THA is not associated with cardiac complications. Initial reports may have represented individual instances of cardiac disease in patients with a failing MoM articulation rather than an emerging epidemiological trend. Cite this article: Bone Joint J 2018;100-B:28–32

Whilst total hip replacement (THR) is generally safe and effective, pre-existing medical conditions, particularly those requiring inpatient admission, may increase the risk of post-operative mortality. Delaying elective surgery may reduce the risk, but it is unclear how long a delay is sufficient. We analysed 958,145 primary THRs performed for solely osteoarthritis April 2003-December 2018, in the NJR linked to Hospital Episodes Statistics to identify inpatient admissions prior to elective THR for 17 conditions making up the Charlson index including myocardial infarction, congestive heart failure, cerebrovascular disease and diabetes. Crude analyses used Kaplan-Meier and adjusted analyses used Cox modelling. Patients were categorised for each co-morbidity into one of four groups: not recorded in previous five-years, recorded between five-years and six-months before THR, recorded six-months to three-months before THR, and recorded between three-months and day before surgery. 90-day mortality was 0.34% (95%CI: 0.33–0.35). In the 432 patients who had an acute MI in the three months before THR, this figure increased to 18.1% (95%CI 14.8, 22.0). Cox models observed 63 times increased hazard of death within 90-days if patients had an acute MI in the 3-months before their THR, compared to patients who had not had an MI in the five years before their THR (HR 63.6 (95%CI 50.8, 79.7)) This association reduced as the time between acute MI and THR increased. For congestive cardiac failure, the hazard in the same scenario was 18-times higher with a similar protective effect of delaying surgery. Linked NJR and HES data demonstrate an association between inpatient admission for acute medical co-morbidities and death within 90-days of THR. This association is greatest in MI, congestive cardiac failure and cerebrovascular disease with smaller associations observed in several other conditions including diabetes. The hazard reduces when longer delays are seen between the admission for acute medical conditions and THR in all diagnoses. This information will help patients with previous medical admissions and surgeons to determine optimal timing for surgery

Aim. Sepsis is a life-threatening complication of periprosthetic joint infections (PJI) that requires early and effective therapy. This study aims to investigate the epidemiology, associated risk factors, and outcome of sepsis in the context of periprosthetic joint infections (PJI). Method. This single-center retrospective cohort study included patients treated for PJI from 2017 to 2020. Patients were classified based on the criteria of the European Bone and Joint Infection Society. The presence of sepsis was determined using the SOFA score and SIRS criteria. The cohort with PJI and sepsis (sepsis) was compared to patients with PJI without sepsis (non-sepsis). Risk factors considered were patient characteristics, affected joints, surgical therapy, microbiological findings, preexisting medical conditions, clinical symptoms, and symptom duration. Outcome parameters were mortality, length of hospital stay, and length of stay in the intensive care unit. Results. A total of 109 patients with PJI were identified, of whom 45 patients (41.3%) met the criteria for sepsis. Patients with sepsis had more severe preexisting diseases compared with the non-sepsis cohort (Charlson Comorbidity Index 3.8 vs. 2.8; p≤0.001). An increased odds ratio (OR) for a septic course was found for the comorbidities pneumonia (8.2; p=0.001), myocardial infarction (2.0; p=0.02), atrial fibrillation (3.3; p=0.01), diabetes mellitus (1.2; p=0.04), endocarditis (5.5; p=0.01), and renal disease (2.0; p≤0.001). Infection with Staphylococcus aureus (sepsis 20 vs. non-sepsis 10; p=0.002), Streptococcus dysgalactiae (sepsis 7 vs. non-sepsis 2; p=0.002) and Candida albicans (sepsis 5 vs. non-sepsis 0; p=0.01) were more prevalent in patients with sepsis. In the sepsis cohort, further infectious foci were present in addition to PJI in 57.8% of patients, compared to 18.8% in the non-sepsis cohort. The presence of sepsis was associated with a longer hospital stay (sepsis 68 days vs. non-sepsis 38 days; p=0.001) and longer intensive care unit stay (sepsis 12 days vs. non-sepsis 2 days; p=0.001). In-hospital mortality was ten times higher in the sepsis cohort compared to non-septic patients (sepsis 11/42 vs. non-sepsis 2/64; OR 10.3; p=0.01). Conclusions. In a relevant proportion of patients, PJI can lead to a septic course of disease associated with increased mortality. Particularly in patients with preexisting diseases, increased attention is required, and comprehensive screening for other foci of infection seems mandatory. In addition to highly virulent pathogens such as staphylococci and streptococci, fungal infections should be considered as causative pathogens in septic patients with PJI

Introduction: Compromised by pre-existing medical co-morbidities, weakened by the second hit of surgery, elderly patients with hip fractures are amongst the most challenging cases to manage appropriately in the acute hospital setting. Aim: To document the frequency and outcome of post operative medical complications in elderly patients following surgery for hip and proximal femoral fractures. Methods: Retrospective analysis of acute admissions to a University teaching hospital with hip and pertrochanteric fractures over an 18 month period. Medical records and radiographs were reviewed for details relating to location of fracture, in-patient morbidity, mortality and length of stay. In-patient fracture referrals and patients under 65 years of age were excluded. Results: From a total of 438 fracture fixation procedures or prosthetic replacements, 368 patients were eligible for analysis. The mean age of patients was 83.6 years. The mean length of stay was 14.2 days. 142 patients experienced significant postoperative morbidity consisting of 24 myocardial infarctions, 46 respiratory tract infections, 33 urinary tract infections, 3 cerebral vascular accidents and 36 exacerbations of congestive cardiac failure. There was no correlation between morbidity and location or type of fracture. The mean age (86.1 yrs) and length of stay (26 days) was greater in the morbidity group (p< 0.05). The overall post operative in-patient mortality rate was 9%, rising to 50% in those who suffered a myocardial infarction and 33% in those with exacerbations of congestive cardiac failure. Conclusion: This study reinforces the poor prognosis conferred by a hip fracture on the elderly patient both in terms of morbidity and mortality. As the population ages and life expectancy increases, health services will come under ever more pressure to cater for the expansion in numbers of hip fracture patients. Greater resources and dedicated professional medical staff are required in order that the best possible care and outcome may be achieved for these patients

In our department we use an enhanced recovery protocol for joint replacement of the lower limb. This incorporates the use of intravenous tranexamic acid (IVTA; 15 mg/kg) at the induction of anaesthesia. Recently there was a national shortage of IVTA for 18 weeks; during this period all patients received an oral preparation of tranexamic acid (OTA; 25 mg/kg). This retrospective study compares the safety (surgical and medical complications) and efficacy (reduction of transfusion requirements) of OTA and IVTA. During the study period a total of 2698 patients received IVTA and 302 received OTA. After adjusting for a range of patient and surgical factors, the odds ratio (OR) of receiving a blood transfusion was significantly higher with IVTA than with OTA (OR 0.48 (95% confidence interval 0.26 to 0.89), p = 0.019), whereas the safety profile was similar, based on length of stay, rate of readmission, return to theatre, deep infection, stroke, gastrointestinal bleeding, myocardial infarction, pneumonia, deep-vein thrombosis and pulmonary embolism. The financial benefit of OTA is £2.04 for a 70 kg patient; this is amplified when the cost saving associated with significantly fewer blood transfusions is considered. Although the number of patients in the study is modest, this work supports the use of OTA, and we recommend that a randomised trial be undertaken to compare the different methods of administering tranexamic acid. Cite this article: Bone Joint J 2013;95-B:1556–61

Aims. The aims of this study were to compare the efficacy of two agents, aspirin and warfarin, for the prevention of venous thromboembolism (VTE) after simultaneous bilateral total knee arthroplasty (SBTKA), and to elucidate the risk of VTE conferred by this procedure compared with unilateral TKA (UTKA). Patients and Methods. A retrospective, multi-institutional study was conducted on 18 951 patients, 3685 who underwent SBTKA and 15 266 who underwent UTKA, using aspirin or warfarin as VTE prophylaxis. Each patient was assigned an individualised baseline VTE risk score based on a system using the Nationwide Inpatient Sample. Symptomatic VTE, including pulmonary embolism (PE) and deep vein thrombosis (DVT), were identified in the first 90 days post-operatively. Statistical analyses were performed with logistic regression accounting for baseline VTE risk. Results. The adjusted incidence of PE following SBTKA was 1.0% (95% confidence interval (CI) 0.86 to 1.2) with aspirin and 2.2% (95% CI 2.0 to 2.4) with warfarin. Similarly, the adjusted incidence of VTE following SBTKA was 1.6% (95% CI 1.1 to 2.3) with aspirin and 2.5% (95% CI 1.9 to 3.3) with warfarin. The risk of PE and VTE were reduced by 66% (odds ratio (OR) 0.44, 95% CI 0.25 to 0.78) and 38% (OR 0.62, 95% CI 0.38 to 1.0), respectively, using aspirin. In addition, the risk of PE was 204% higher for patients undergoing SBTKA relative to those undergoing UTKA. For each ten-point increase in baseline VTE risk, the risk of PE increased by 25.5% for patients undergoing SBTKA compared with 10.5% for those undergoing UTKA. Patients with a history of myocardial infarction or peripheral vascular disease had the greatest increase in risk from undergoing SBTKA instead of UTKA. Conclusion. Aspirin is more effective than warfarin for the prevention of VTE following SBTKA, and serves as the more appropriate agent for VTE prophylaxis for patients in all risk categories. Furthermore, patients undergoing SBTKA are at a substantially increased risk of VTE, even more so for those with significant underlying risk factors. Patients should be informed about the risks associated with undergoing SBTKA. Cite this article: Bone Joint J 2018;100-B(1 Supple A):68–75

Objectives. We have increased the dose of tranexamic acid (TXA) in our enhanced total joint recovery protocol at our institution from 15 mg/kg to 30 mg/kg (maximum 2.5 g) as a single, intravenous (IV) dose. We report the clinical effect of this dosage change. Methods. We retrospectively compared two cohorts of consecutive patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) surgery in our unit between 2008 and 2013. One group received IV TXA 15 mg/kg, maximum 1.2 g, and the other 30 mg/kg, maximum 2.5 g as a single pre-operative dose. The primary outcome for this study was the requirement for blood transfusion within 30 days of surgery. Secondary measures included length of hospital stay, critical care requirements, re-admission rate, medical complications and mortality rates. Results. A total of 1914 THA and 2537 TKA procedures were evaluated. In THA, the higher dose of TXA was associated with a significant reduction in transfusion (p = 0.02, risk ratio (RR) 0.74, 95% confidence interval (CI) 0.58 to 0.96) and rate of re-admission (p < 0.001, RR 0.50, 95% CI 0.35 to 0.71). There were reductions in the requirement for critical care (p = 0.06, RR 0.55, 95% CI 0.31 to 1.00), and in the length of stay from 4.7 to 4.3 days (p = 0.02). In TKA, transfusion requirements (p = 0.049, RR 0.64, 95% CI 0.41 to 0.99), re-admission rate (p = 0.001, RR 0.56, 95% CI 0.39 to 0.80) and critical care requirements (p < 0.003, RR 0.34, 95% CI 0.16 to 0.72) were reduced with the higher dose. Mean length of stay reduced from 4.6 days to 3.6 days (p < 0.01). There was no difference in the incidence of deep vein thrombosis, pulmonary embolism, gastrointestinal bleed, myocardial infarction, stroke or death in THA and TKA between cohorts. Conclusion. We suggest that a single pre-operative dose of TXA, 30 mg/kg, maximum 2.5g, results in a lower transfusion requirement compared with a lower dose in patients undergoing elective primary hip and knee arthroplasty. However, these findings should be interpreted in the context of the retrospective non-randomised study design. Cite this article: R. J. M. Morrison, B. Tsang, W. Fishley, I. Harper, J. C. Joseph, M. R. Reed. Dose optimisation of intravenous tranexamic acid for elective hip and knee arthroplasty: The effectiveness of a single pre-operative dose. Bone Joint Res 2017;6:499–505. DOI: 10.1302/2046-3758.68.BJR-2017-0005.R1

Aims. The place of thromboprophylaxis in arthroplasty surgery remains controversial, with a challenging requirement to balance prevention of potentially fatal venous thrombo-embolism with minimising wound-related complications leading to deep infection. We compared the incidence of fatal pulmonary embolism in patients undergoing elective primary total hip arthroplasty (THA) between those receiving aspirin, warfarin and low molecular weight heparin (LMWH) for the chemical component of a multi-modal thromboprophylaxis regime. Patients and Methods. A prospective audit database was used to identify patients who had died within 42 and 90 days of surgery respectively between April 2000 and December 2012. A case note review was performed to ascertain the causes of death. Results. During this period 7983 THAs were performed. The rate of mortality was 0.43% and 0.58% at 42 and 90 days respectively. The groups comprised 1571 patients (19.7%) on warfarin, 1838 (23.0%) on LMWH and 4574 (57.3%) on aspirin. The 90-day mortality for these three groups was 0.38%, 1.09% and 0.43% respectively. The higher mortality rate for LMWH was significant (p < 0.05). There were six fatal pulmonary emboli (PEs) (0.08%). A total of three occurred within 42 days, all in the LMWH group. A total of three occurred between 42 and 90 days; one on warfarin, two on LMWH. The leading causes of death in all three groups were lower respiratory tract infections and myocardial infarction. Conclusion. We confirmed that fatal PE following elective THA with a multi-modal prophylaxis regime is rare. We further found that LMWH conferred no benefit over aspirin in this context, and is associated with a higher all-cause rate of mortality. Take home message: This study proposes that aspirin may be an appropriate thromboprophylaxis agent when used as part of a multi-modal regimen, suggesting current guidelines should be reviewed. Cite this article: Bone Joint J 2016;98-B:585–8

Objectives. To determine the morbidity and mortality outcomes of patients presenting with a fractured neck of femur in an Australian context. Peri-operative variables related to unfavourable outcomes were identified to allow planning of intervention strategies for improving peri-operative care. Methods. We performed a retrospective observational study of 185 consecutive adult patients admitted to an Australian metropolitan teaching hospital with fractured neck of femur between 2009 and 2010. The main outcome measures were 30-day and one-year mortality rates, major complications and factors influencing mortality. . Results. The majority of patients were elderly, female and had multiple comorbidities. Multiple peri-operative medical complications were observed, including pre-operative hypoxia (17%), post-operative delirium (25%), anaemia requiring blood transfusion (28%), representation within 30 days of discharge (18%), congestive cardiac failure (14%), acute renal impairment (12%) and myocardial infarction (4%). Mortality rates were 8.1% at 30 days and 21.6% at one year. Factors predictive of one-year mortality were American Society of Anesthesiologists (ASA) score (odds ratio (OR) 4.2 (95% confidence interval (CI) 1.5 to 12.2)), general anaesthesia (OR 3.1 (95% CI 1.1 to 8.5)), age > 90 years (OR 4.5 (95% CI 1.5 to 13.1)) and post-operative oliguria (OR 3.6 (95% CI 1.1 to 11.7)). Conclusions. Results from an Australian metropolitan teaching hospital confirm the persistently high morbidity and mortality in patients presenting with a fractured neck of femur. Efforts should be aimed at medically optimising patients pre-operatively and correction of pre-operative hypoxia. This study provides planning data for future interventional studies. Cite this article: Bone Joint Res 2013;2:162–8

Background. There are advantages and disadvantages of Unicompartmental (UKR) and Total Knee Replacement, with UKR having better functional outcomes with fewer complications but a higher revision rate. The relative merits depend on patient characteristics. The aim was to compare UKR and TKR risk-benefits and cost-effectiveness in patients with severe systemic morbidity. Methods. Data from the National Joint Registry for England, Wales and Northern Ireland was linked to hospital inpatient and patient-reported outcomes data. Patients with American Society of Anesthesiologists (ASA) grade ≥3 undergoing UKR or TKR were identified. Propensity score stratification was used to compare 90-day complications and 5-year revision and mortality of 2,256 UKR and 57,682 TKR, and in a subset of 145 UKR and 23,344 TKR Oxford Knee Scores (OKS). A health-economic analysis was based on EQ-5D and NHS hospital costs. Results. The OKS was significantly better following UKR than TKR with a difference of 1.83 (95%CI 0.10–3.56). UKR was associated with lower relative risks of venous thromboembolism (0.33, CI0.15–0.74), myocardial infarction (0.73, CI0.36–1.45) and early joint infection (0.85, CI0.33–2.19) but only the decrease in venous thromboembolism was significant. The revision risk following UKR was significantly higher than following TKR (hazard ratio 2.70, CI2.15–3.38) and the mortality was significantly lower (0.52, CI0.36–0.74). At five years the cumulative incidence of revision was 8% higher with UKR, and the cumulative incidence of death was 13% lower. The health economic analysis found that UKR dominated TKR having lower costs (£359, CI340-378) and higher quality-of-life gains (0.33, CI-0.31–0.970). Conclusions. For patients with ASA ≥3, UKR was safer and more cost-effective than TKR. In particular if UKR was used instead of TKR the number of lives saved was higher than the number of extra revisions. UKR should be considered the first option for suitable patients with severe co-morbidity

Disarticulation of the hip in patients with high-grade tumours in the upper thigh results in significant morbidity. In patients with no disease of the proximal soft tissue a femoral stump may be preserved, leaving a fulcrum for movement and weight-bearing. We reviewed nine patients in whom the oncological decision would normally be to disarticulate, but who were treated by implantation of an endoprosthesis in order to create a functioning femoral stump. The surgery was undertaken for chondrosarcoma in four patients, pleomorphic sarcoma in three, osteosarcoma in one and fibrous dysplasia in one. At follow-up at a mean of 80 months (34 to 132), seven patients were alive and free from disease, one had died from lung metastases and another from a myocardial infarction. The mean functional outcome assessment was 50 (musculoskeletal tumor society), 50 and 60 (physical and mental Short-form 36 scores). Implantation of an endoprosthesis into the stump in carefully selected patients allows fitting of an above-knee prosthesis and improves wellbeing and the functional outcome

Fragility fractures of the ankle occur mainly in elderly osteoporotic women. They are inherently unstable and difficult to manage. There is a high incidence of complications with both non-operative and operative treatment. We treated 12 such fractures by closed reduction and stabilisation using a retrograde calcaneotalotibial expandable nail. The mean age of patients was 84 years (75 to 95). All were women and were able to walk fully weight-bearing after surgery. There were no wound complications. One patient died from a myocardial infarction 24 days after surgery. The 11 other patients were followed up for a mean of 67 weeks (39 to 104). All the fractures maintained satisfactory alignment and healed without delay. Six patients refused removal of the nail after union of the fracture. The functional rating using the scale of Olerud and Molander gave a mean score at follow-up of 61, compared with a pre-injury value of 70

DAIR procedure is well established for Prosthetic Joint Infection (PJI) in acute setting after total hip and knee replacements. We present our experience of DAIR following hip and knee replacements in a District General Hospital (DGH), where we delivered comparable results to leading tertiary centres in short to mid-term followup. We undertook a retrospective study involving 14 patients, who underwent DAIR in our DGH between August 2012 and December 2015. Patient cohort included primary, complex primary and revision hip and knee replacements. Microbiological support was provided by a Microbiologist with interest in musculoskeletal infections. 14 patients [9 males, 5 females; age 62 to 78 years (Mean 70.7); BMI 22 to 44.2 (Mean 33.8)] with multiple comorbidities underwent DAIR procedure within 3 weeks of onset of symptoms. 12 out of 14 grew positive cultures with two growing Vancomycin resistant Enterococci. Intravenous antibiotics were started after multiple samples intraoperatively and continued in six patients after discharge, while 8 were discharged with oral antibiotics. One patient died of overwhelming intraoperative septic shock in postoperative period. Another patient died of myocardial infarction subsequently. 12 (85.7%) patients were doing well with regular followup (Mean 20 months). With good patient selection, DAIR is a far simpler solution and a safe and reproducible surgical option for early PJI following hip and knee replacements compared to one or two stage revisions. But published data in contemporary literature is predominantly from specialised centres. Our small series provides a perspective of comparable early to mid-term results of DAIR from DGH

OBJECTIVE. Debridement, Antibiotics and Implant Retention (DAIR) procedure is well established for Prosthetic Joint Infection (PJI) in acute setting after total hip and knee replacements. We present our perspective of DAIR in a relatively a small cohort following hip and knee replacements in a District General Hospital (DGH) in United Kingdom, where we delivered comparable results to leading tertiary centers in short to mid-term followup. METHODS. We undertook a retrospective study involving 14 patients, who underwent DAIR in our DGH between August 2012 and December 2015. Patient cohort included primary, complex primary and revision hip and knee replacements. Multiple samples were taken intraoperatively for cultures and histology. mMicrobiological support was provided by a microbiologist with interest in musculoskeletal infections. RESULTS. 14 patients [9 males, 5 females; age 62–78 years (Mean 70.7); BMI 22–44.2 (Mean 33.8)] with multiple comorbidities underwent DAIR procedure within 3 weeks of onset of symptoms, (although the time from index surgery ranged from 15 days to 58 months). Patient selection was made by two Hip surgeons. 12 out of 14 grew positive cultures with two growing Vancomycin resistant Enterococcus. IV antibiotics were stated after samples intraoperatively and continued in six patients after discharge using (OPAT), while 8 were discharged with oral antibiotics. One patient died in immediate post operative period due to generalised sepsis. Another patient died of myocardial infarction 2 years after DAIR. 12 (85.7%) patients are doing well with regular followup (Mean 20 months) in clinics. CONCLUSIONS. With good patient selection, DAIR is a far simpler solution and a safe and reproducible surgical option in PJI in hip and knee replacements compared to one or two stage revisions with the implications. But published Data in contemporary literature is predominantly from specialized centers. Our small series provides a perspective of early to mid term results of DAIR from a DGH

Introduction. Smoking, a modifiable factor, may adversely affect post-operative outcomes. Healthcare providers are increasingly denying smokers access to total hip arthroplasty (THA) until they stop smoking. Evidence supporting this is unclear. We assessed the effect of smoking on outcomes following THA. Patients and Methods. We performed a retrospective observational study involving 60,812 THAs (12.4%=smokers, 31.2%=ex-smokers, 56.4%=non-smokers) from the Clinical Practice Research Datalink. Data were linked with Hospital Episode Statistics and the Office for National Statistics to identify outcomes. The effect of smoking on post-operative outcomes (complications, medications, revision, mortality, PROMs) was assessed using adjusted regression. Results. Following THA, smokers had a significantly increased risk of lower respiratory tract infection (odds ratio (OR)=0.53; 95% CI=0.43–0.64), myocardial infarction (OR=0.41; CI=0.24–0.71), cerebrovascular disease (OR=0.54; CI=0.32–0.93), and ischaemic heart disease (OR=0.62; CI=0.43–0.91) compared with non-smokers. The risk of these complications in smokers was also significantly higher compared with ex-smokers. The risk of other complications, including DVT and wound infection, was similar between smoking groups. Compared with non-smokers (OR=0.55; CI=0.51–0.60) and ex-smokers (OR=0.85; CI=0.78–0.92), smokers had increased opioid usage at one-year post-surgery. Similar patterns were observed for weak opioids and paracetamol. One-year mortality rates were higher in smokers compared with non-smokers (hazard ratio (HR)=0.39, CI=0.30–0.50) and ex-smokers (HR=0.50, CI=0.39–0.65). Long-term revision rates were not increased in smokers. Smokers had significant improvement in PROMs compared with pre-operatively, with no clinically important difference in postoperative PROMs between smokers, non-smokers and ex-smokers. Discussion. Smoking was associated with more medical complications (namely vascular), higher analgesia usage, and increased mortality following THA. Most adverse outcomes were reduced in ex-smokers, therefore smoking cessation should be encouraged before arthroplasty. However, THA is clinically effective in smokers, who gain meaningful PROM improvement with no increased revision risk. Conclusion. Smokers should not be universally denied access to primary THA

Introduction. With the rising utilization of total joint arthroplasty, the role of simultaneous-bilateral surgery has expanding impact. The purpose of this study is to examine the risk of perioperative complications for this approach in total knee arthroplasty to inform shared decision making. Methods. We used nation-wide linked discharge data from the Hospital Cost and Utilization Project from 2005–2014 comparing outcomes of simultaneous-bilateral and staged-bilateral total knee arthroplasties (TKAs). Hierarchical logistic regression analysis was used to compare mortality within 30 days, 90 days and 1 year, perioperative risks within 30–60 days, and infection and mechanical complications within 1 year. Results. 63,579 patients were analyzed including 27,301 simultaneous-bilateral and 36,278 staged-bilateral TKAs. Patients who underwent simultaneous surgery had a significantly higher adjusted odds ratio of death within 30 days (OR=3.31, 95% CI=2.15–5.08, p<0.001), myocardial infarction (OR=2.54, 95% CI=1.96–3.28, p<0.001), ischemic stroke (OR=2, 95% CI=1.39–2.87, p=0.002), cardiac complications (OR=1.3, 95% CI=1.12–1.5, p=0.007), digestive complications (OR=1.85, 95% CI=1.59–2.15, p<0.001), deep vein thrombosis (OR=1.31, 95% CI=1.18–1.45, p<0.001), and pulmonary embolism (OR=1.76, 95% CI=1.49–2.08, p<0.001) with a lower adjusted odds ratio of hematoma (OR=0.55, 95% CI=0.45–0.68, p<0.001), knee infection (OR=0.83, 95% CI=0.71–0.98, p=0.023), and major mechanical malfunction (OR=0.78, 95% CI=0.65–0.94, p=0.009). There was no difference in the adjusted OR for minor mechanical malfunction. The absolute risk difference for any complication between groups was 1% or less. Conclusion. Despite higher odds of experiencing many complications for patients undergoing simultaneous-bilateral versus staged total knee arthroplasty, the absolute difference in perioperative risks between these groups is small. This study of a large population informs surgeons and patients regarding the safety of simultaneous surgery. Level of Evidence: Therapeutic Level III. Keywords: knee arthroplasty; simultaneous; bilateral; staged; joint replacement

Background. As the number of total knee arthroplasties (TKA) being performed continues to increase, the number of potential failures requiring revision surgery would also be expected to increase. This study analyzed the trends in revision TKA (rTKA) from 2009 to 2016. Methods. The Nationwide Inpatient Sample (NIS) database was used to identify all rTKA by International Classification of Diseases, Ninth Revision (ICD-9) and Tenth Revision (ICD-10) codes. The diagnoses leading to revision, revision costs, patient and hospital characteristics, and major inpatient complications were compared between 2009 and 2016. Multivariate logistic regression analyses were used to calculate odds ratios (OR) for complications. Results. A total of 453,770 rTKA were performed between 2009 and 2016 (Table 1). The incidence of rTKA between 2009 and 2016 decreased by 4.3% among all age groups and decreased 5.9% in those over 65 years of age. The mean age at revision remained unchanged at 65 years, the mean Length of Stay (LOS) decreased 19.5% from 4.1 to 3.3 days (p<0.001), and the mean hospital costs increased 18.7% from $23,103 to $27,427 (p<0.001). Male to Female ratio remained unchanged with Females making up 58% of rTKA. The rTKA patients in 2016 versus 2009 had significantly lower odds of requiring a blood transfusion (OR 0.26, p<0.001). The rate of myocardial infarction remained unchanged in 2016 versus 2009 (4.1% vs. 4.0%, p=0.52), as did mortality (0.1% vs. 0.2%, p=0.089). Patients in 2016 were significantly less likely to be discharged to a skilled nursing facility (SNF) (26.5% in 2016 vs. 31.6% in 2009, p<0.001). A significantly larger share of rTKA were performed in urban teaching hospitals in 2016 (66.6% in 2016 vs. 41.5% in 2009, p<0.001). Mechanical loosening remained the most common reason for rTKA and increased from 19.7% in 2009 to 28.4% in 2016. Infection remained the second most common reason for rTKA (14.7% in 2009 vs. 12.2% in 2016). Instability was the third most common reason for revision in 2016 (10.7%) but direct comparison with 2009 could not be made since ICD-9 did not include this diagnosis. When comparing 2009 to 2014, an increase in revision rates was noted. Upon inclusion of 2015 and 2016 data, a decrease is noted. The primary limitation of this study is the challenge faced when comparing results from before and after the October 2015 transition of ICD-9 to ICD-10 codes. Conclusions. The incidence of rTKA had decreased slightly between 2009 and 2016 even while the volume of primary TKA continued to rise. Implant loosening became increasingly prevalent as a reason for revision and infection continued to plague patients after TKA. Positive trends were noted, such as decreased rates of blood transfusion, LOS and rates of discharge to SNF. Still, the revision burden remains large, costing approximately $1.4 billion annually and we must continue to attempt to improve outcomes in this patient population. For figures, tables, or references, please contact authors directly

Venous thromboembolism (VTE) prophylaxis following total joint arthroplasty (TJA) should be individualised in order to maximise the efficacy of prophylactic measures while avoiding the adverse events associated with the use of anticoagulants. At our institution, we have developed a scoring model using the Nationwide Inpatient Sample (NIS) database, which is validated against our institutional data, to stratify patients into low- and high-risk groups for VTE. Low-risk patients are placed on aspirin 81 mg twice daily for four weeks post-operatively, and high-risk patients are placed on either a Vitamin K antagonist (warfarin), low molecular weight heparin, or other oral anticoagulants for four weeks post-operatively. All patients receive sequential pneumatic compression devices post-operatively, and patients are mobilised with physical therapy on the day of surgery. Patients who have a history of peptic ulcer disease or allergy to aspirin are also considered for other types of anticoagulation following surgery. Risk Stratification Criteria. Major comorbid risk factors utilised in our risk stratification model include history of hypercoagulability or previous VTE, active cancer or history of non-cutaneous malignancy, history of stroke, and pulmonary hypertension. We consider patients with any of these risk factors at elevated risk of VTE and therefore candidates for formal anticoagulation. Other minor risk factors include older age, bilateral surgery compared with unilateral, inflammatory bowel disease, varicose veins, obstructive sleep apnea, and history of myocardial infarction, myeloproliferative disorders, and congestive heart failure. Each minor criterion is associated with a score. The cumulative score is compared with a defined threshold and the score that surpasses the threshold indicates that the patient should receive post-operative anticoagulation. To facilitate the use of this scoring system, an iOS mobile application (VTEstimator) has been developed and can be downloaded from the app store

Perioperative blood management remains a challenge during total hip and total knee arthroplasty (THA and TKA, respectively). The purpose of this study was to determine the impact of body mass index (BMI) on blood transfusion in THA and TKA. We retrospectively evaluated 2399 patients, of whom 896 underwent THA and 1503 had TKA. A variety of outcome variables were assessed for their relationship to BMI which was stratified using the World Health Organization (WHO) classification scheme (Normal <25 kg/m2, Overweight 25–30, and Obese >30). Increased BMI was found to be protective of blood transfusion in both THA and TKA patients. Among THA patients, transfusion rates were 34.8%, 27.6% and 21.9% for normal, overweight and obese categories respectively (p = 0.002). TKA transfusion rates were 17.3%, 11.4% and 8.3% for the same categorization of BMI (p = 0.002). No trends were identified for a relationship between BMI and deep vein thrombosis, pulmonary embolism, myocardial infarction, discharge location, length of stay, 30-day readmission rate and preoperative hemoglobin level. Elevated BMI was significantly associated with decreased age, increased Hemoglobin A1c, increased baseline creatinine, increased OR time, increased American Society of Anesthesiologists (ASA) score and increased estimated blood loss in both THA and TKA patients. There was a statistically significant trend toward increased deep surgical site infection in THA patients (p = 0.043)

Introduction & aims. Total hip replacement is an excellent treatment option for people with late stage degenerative hip disease. In addition to marked reduction in pain and improvement in sleep, most people regain range of motion, physical ability and quality of life. This study aimed at the functional outcomes of large diameter heads in THR patients. Method. This study is an analysis of a cohort of patients undergoing total hip replacement performed at our hospital from November 2011 to July 2013. A total of 70 hips, 40 males and 30 females, were operated upon with large diameter femoral heads. The mean age was 50.38 years (range 40–59 years). In our cohort, 32 patients had AVN of femur head, 19 had post traumatic secondary degeneration, 10 had RA, 6 had AS and 3 patients had OA of hip. The follow-up data included local complications, Harris Hip Score, medical complications, readmission, activity status and use of a walking aid. Results. Harris hip score at final follow up was, 33 cases had excellent, 26 cases had good result. None of the patient had fair or poor result. Two cases of superficial infection were observed. One case of dislocation was observed in post operative period which was reduced under GA and patient was given abduction brace. The mean follow up was 16.31 months ranging from 6 to 32 months. During the follow up, we had mortality of two patients. One died at 14 months due to myocardial infarction and the cause of other died due to CVA at 10 months follow up. Conclusions. Lower dislocation rate and better range of motion in majority of cases reinforces the advantage of large diameter head in THR in young and active patients. For any figures or tables, please contact authors directly (see Info & Metrics tab above).

Bilateral one stage total knee replacement (TKR) has a number of advantages. There is one operative procedure and anesthetic and overall recovery time is significantly reduced. It is a more cost-effective procedure in that acute hospital stay is less and although rehabilitation time is greater in the short term, overall it is less. Additionally, if there is a bilateral flexion contracture present there is an inevitable loss of extension if a single knee is operated upon as this knee will assume the position of the unoperated knee. Patients greatly prefer having both knees corrected at one operative setting rather than having to have the inconvenience and pain associated with a second operative procedure at three to six months after the first one. There are potential disadvantages to a one stage procedure. One concern has been that there is more peri-operative morbidity associated with one stage bilateral total knee replacement. In a review of 501 patients undergoing bilateral one stage total knee replacement at the Hospital for Special Surgery (HSS) there were no peri-operative deaths, myocardial infarctions or cerebrovascular accidents. There were arrhythmias present in 5% of patients. Fat emboli were present in 3% and 2 patients (0.4%) had pulmonary emboli. The average transfusion requirement was 2.6 units and allogeneic blood was required in 42%. There were 2 deep infections, 3 hematomas and 5 patients with delayed wound healing There was an increased incidence of major complications in patients with ASA classification 3 and with increasing age over 70 years. New data indicates peri-operative administration of hydrocortisone may mitigate lung injury as demonstrated by reduction in cytokine and desmosine levels in a randomised trial. There was also a trend toward less need for narcotic medication and better range of motion in the steroid treated group. Patient selection is important and all patients are screened pre-operatively by an internist and anesthesiologist. In over 3000 bilateral TKRs at HSS infection rate and mortality were lower than in the unilateral total knee replacement patients. Much of this is due to patient selection criteria. All patients underwent the procedure with epidural anesthesia with post-operative epidural PCA for 48 hours. All patients are discharged on warfarin and spend the operative night in the recovery room. The procedure has acceptable morbidity and great advantage in properly selected patients

Aim. Our aim was to evaluate cementless one-stage revision in chronic periprosthetic hip joint infection. Method and patients. The study was performed as a multicentre, proof-of-concept, observational study with prospective data collection. Inclusion of patients with a chronic periprosthetic hip joint infection (PJI) were followed by protocolled surgical treatment (cementless one-stage revision - the CORIHA protocol) at one of 8 participating departments of orthopaedic surgery between 2009 – 2014, and the patients enrolled in a 2-year follow-up program. A PJI were diagnosed based on adopted criteria from McPherson and Zimmerli. At the time of initiation of the study in 2009, the collaborating departments performed approximately one-fourth of all nationwide primary HJR and more than one-third of all revisions. In total 56 PJI patients with a median age of 72 years and a median pre-operative ASA score of 2 met the established eligibility criteria and accepted to participate; 31 (55%) were males. The cohort had a mean follow-up time of 4.0 years, with all patients followed for minimum 2 years. The primary outcome were relapse described as re-revision due to infection (regardless of considered as a relapse or new infection). This was evaluated by competing risk analysis (competing risks: aseptic revisions and death). Secondary, all-cause mortality was evaluated by survival analysis. The study was approved by the local Committees on Biomedical Research Ethics. Results. Five patients were revised due to relapse of infection. The cumulative incidence of re-revision due to infection was 8.9% (95% Confidence Interval 3.2–18.1). Seven patients had died in the follow-up period. None of these were believed to have been re-infected. The 1 and 5 year survival incidence was 96 (95% Confidence Interval 86–99) and 89 (95% Confidence Interval 75–95). Several complications were registered in the follow-up period: Three patients sustained periprosthetic fractures. Five patients had closed reduction due to dislocation - none have been open revised. Five patients sustained acute renal failure without long-term complications. One patient suffered an acute non-stemi myocardial infarction 8 days post-operatively, but with no major sequelae. One patient had soft-tissue revision of the wound following the CORIHA surgery, but is believed free of infection; One patient has severe irritation by the cables left from the extended osteotomy, but no further surgery is planned. Conclusions. We found that cementless one-stage revision in chronic hip PJI is a valuable treatment. This method has gained nationwide acceptance as first-line treatment strategy following this study

Bilateral one stage total knee replacement has a number of advantages. There is one operative procedure and anesthetic and overall recovery time is significantly reduced. It is a more cost effective procedure in that acute hospital stay is less and although rehabilitation time is greater in the short term overall it is less. Additionally if there is a bilateral flexion contracture present there is an inevitable loss of extension if a single knee is operated upon as this knee will assume the position of the unoperated knee. Patients greatly prefer having both knees corrected at one operative setting rather than having to have the inconvenience and pain associated with a second operative procedure at three to six months after the first one. There are potential disadvantages to a one stage procedure. One concern has been that there is more peri-operative morbidity associated with one stage bilateral total knee replacement. In a review of 501 patients undergoing bilateral one stage total knee replacement at the Hospital for Special Surgery there were no peri-operative deaths, myocardial infarctions or cerebrovascular accidents. There were arrhythmias present in 5% of patients. Fat emboli were present in 3% and 2 patients (0.4%) had pulmonary emboli. The average transfusion requirement was 2.6 units and allogeneic blood was required in 42%. There were 2 deep infections, 3 hematomas and 5 patients with delayed wound healing. There was an increased incidence of major complications in patients with ASA classification 3 and with increasing age over 70 years. New data indicates peri-operative administration of hydrocortisone my mitigate lung injury as demonstrated by reduction in cytokine and desmosine levels in a randomised trial. There was also a trend toward less need for narcotic medication and better range of motion in the steroid treated group. Patient selection is important and all patients are screened pre-operatively by an internist and anesthesiologist. In over 3000 bilateral TKR at HSS infection rate and mortality were lower than in the unilateral total knee replacement patients. Much of this has is due to patient selection criteria. All patients underwent the procedure with epidural anesthesia with post-operative epidural PCA for 48 hours. All patients are discharged on warfarin and spend the operative night in the recovery room. The procedure has acceptable morbidity and great advantage in properly selected patients

Hip fractures are among the most common orthopaedic injuries and represent a growing burden on healthcare as our population ages. Despite improvements in preoperative optimisation, surgical technique and postoperative care, complication rates remain high. Time to surgery is one of the few variables that may be influenced by the medical team. The aim of the present study was to evaluate the impact of time to surgery on mortality and major complications following surgical fixation of hip fractures. Utilising the American College of Surgeons' National Quality Improvement Program (NSQIP) database, we analysed all hip fractures (femoral neck, inter-trochanteric, and sub-trochanteric) treated from 2011 to 2013 inclusively. We divided patients into three groups based on time to surgery: less than one day (<24h), one to two days (24–48h), and two to five days (48–120h). Baseline characteristics were compared between groups and a multivariate analysis performed to compare 30-day mortality and major complications (return to surgery, deep wound infection, pneumonia, pulmonary embolus, acute renal failure, cerebrovascular accident, cardiac arrest, myocardial infarction, or coma) between groups. A total of 14,730 patients underwent surgical fixation of a hip fracture and were included in our analysis. There were 3,475 (24%) treated <24h, 9,960 (67%) treated 24–48h, and 1,295 (9%) treated 48–120h. Thirty-day mortality and major complication rates were 5.0% and 6.2% for the <24h group, 5.3% and 7.0% for the 24–48h group, 7.9% and 9.7% for the 48–120h group respectively. After controlling for baseline demographic differences between groups (age, sex, race) as well as pertinent comorbidities (diabetes, dyspnea, chronic obstructive pulmonary disease, chronic steroid use, hypertension, cancer, bleeding disorders, and renal failure), time to surgery beyond 48h resulted in greater odds of both mortality (1.45, 95%CI 1.10–1.91) and major complications (1.45, 95%CI 1.12–1.84). Time to surgery is one of the few variables that can be influenced by timely medical assessment and access to the operation room. Expediting surgery within 48h of hip fracture is of paramount importance as it may significantly reduce the risk of mortality as well as major complications

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. Methods. 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). Patients whose length of stay (LOS) was >4 days were excluded. Patient demographics, anesthesia type, length of operation and hospital stay, as well as 30-day major and minor complications were collected from the database. Chi square tests were utilized to compare the unadjusted rates of complications between patients whose LOS was 0, 1, 2, and 3–4 days. Multivariable regression was utilized to evaluate the effect of LOS on complication rates, while adjusting for age, American Society of Anesthesiologist (ASA) class, type of anaesthesia, functional status, comorbidities, sex, steroid/immunosuppressant use, body mass index (BMI), diabetes, length of operation and smoking status. Results. A total of 198,191 TKA patients were identified (average age 66 ± 10 years). Average LOS was 2.5 ± 0.81 days. Of these patients, 1,667 (0.84%) were discharged the day of surgery, while 16,186 (8.17%) were discharged one-day post-surgery, 63,540 (32.06%) were discharged on day two, and 115,471 (58.25%) were discharged between 3 and 4 days post-surgery. Unadjusted rates of complications were significantly higher for patients who were discharged on the day of surgery (2.64%), or those whose LOS was 3–4 days (2.78%) compared to those whose LOS was 1 (1.40%) or 2 days (1.67%). After adjusting for all relevant covariables, discharge on the day of surgery increased the risk of major complications by 1.8 (95% Confidence interval [95%CI] 1.2–2.8), and minor complications by 1.6 (95%CI 1.2 – 2.2) compared to patients whose LOS was 2 days. A LOS of 1 day did not affect the risk of major complications compared to a LOS of 2 days, while a LOS of 3–4 days increased the risk of major complications by 1.4 (95%CI 1.3 – 1.6), and minor complications by 1.6 (95%CI 1.4 – 1.7). Regarding specific complications, same-day discharge remained an independent predictor of myocardial infarction (MI), cardiac arrest, pulmonary embolism (PE), unplanned reintubation, >48 hours on ventilator, pneumonia and renal insufficiency, while a LOS of 3–4 days remained an independent predictor of MI, cardiac arrest, sepsis, acute renal failure, PE, unplanned reintubation, >48 hours on ventilator, stroke, deep vein thrombosis, pneumonia, urinary tract infection, renal insufficiency, deep and superficial surgical site infection, and wound disruption compared to patients whose LOS was 2 days (p<0.01). Conclusion. Discharge on days 1–2 postoperatively following TKA appears to have superior outcomes compared to discharge on the day of surgery, or on days 3–4. Prospective clinical data is required to confirm the effect of discharge timing on postoperative outcomes following TKA

Hemorrhage and transfusion requirements in spine surgery are common. This is especially true for thoracic and lumbar fusion surgeries. The purpose of this papersi to determine predictive factors for transfusion and their effect on short-term post-operative outcomes for thoracic and lumbar fusions. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients that underwent lumbar or thoracic fusion surgery from 2010 to 2013. Univariate and multivariate regression analysis was used to determine predictive factors and post-operative complications associated with transfusion. A total of 14,249 patients were included in this study; 13,586 had lumbar fusion and 663 had thoracic fusion surgery. The prevalence of transfusion was 35% for thoracic fusion and 17.5% for lumbar fusion. The multivariate analysis showed that age between 50–60 (OR 1.38, CI: 1.23–1.54), age between 61–70 (OR 1.65, CI: 1.40–1.95), dyspnea (OR 1.11, CI: 1.02–1.23), hypertension (OR 1.14, CI: 1.02–1.27), ASA class (OR 1.73, 1.18–1.45), pre-operative blood transfusion (OR 1.91, CI: 1.04–3.49), and extended surgical time (OR 4.51, CI: 4.09–4.98) were predictors of blood transfusion requirements for lumbar fusion. While only pre-operative BUN (OR 1.04, CI: 1.01–1.06) and extended surgical time (OR 4.70, CI: 3.12–6.96) were predictors of transfusion for thoracic fusion. In contrast, higher pre-operative hematocrit was protective against transfusion. Patients transfused who underwent lumbar fusion had an increased risk to develop superficial wound infection, deep wound infection, venous thromboembolism, myocardial infarction and had longer length of hospital stay. Patients transfused who underwent thoracic fusion were more likely to have venous thromboembolism and extended length of hospital stay. However, mortality was not associated with blood transfusion. This study used a large database to characterise the incidence, predictors and post-operative complications associated with blood transfusion in thoracic and lumbar fusion surgeries. Pre- and post-operative planning for patients deemed to be at high-risk of requiring blood transfusion should be considered to reduce post-operative complication in this population

Aim. To assess the incidence of fatal pulmonary embolism (PE) following elective total knee replacement (TKR) with a standardised multi-modal prophylaxis regime in a large teaching DGH over a 10 year period. Material and methods. Information was gathered from a prospective audit database, utilising clinical coding for TKR and those that had died within 42 and 90 days. The 10 years from April 2000 were analysed to establish both 42 and 90 day mortality rates. A multi-modal prophylaxis regime for all patients included regional anaesthesia (when possible), mechanical prophylaxis (Flo-tron calf garment per-operatively, AV impulse boots until mobile and anti-embolism stockings for 6 weeks), mobilisation within 24 hours and 75mg aspirin for 4 weeks. A case note review was performed to ascertain the causes of death. Where a patient had been referred to the coroner, the coroner's office was contacted for PM results. Results. There were 6,584 cases; the mortality rates at 42 and 90 days were 0.36 and 0.52%. There were no fatal PE's within 42 days of surgery. 2 fatal PE's occurred subsequently at 48 and 57 days (0.03%) The leading causes of death were myocardial infarction and cerebro-vascular accident. Conclusion. Fatal pulmonary embolus following elective TKR with a multi-modal prophylaxis regime is not a significant cause of mortality

The benefit of using a long intramedullary device for the treatment of geriatric intertrochanteric hip fractures is unknown. The InterTAN device (Smith and Nephew, Memphis TN) is offered in either Short (180–200 mm) or Long (260–460 mm) constructs and was designed to provide stable compression across primary intertrochanteric fracture fragments. The objective of our study was to determine whether Short InterTANs are equivalent to Long InterTANs in terms of functional and adverse outcomes for the treatment of geriatric intertrochanteric hip fractures. 108 patients with OTA classification 31A–1 and 31A–2 intertrochanteric hip fractures were included in our study and prospectively followed at one of four Canadian Level-1 Trauma Centres. Our primary outcomes included two validated primary outcome measures: the Functional Independence Measure (FIM), to measure function, and the Timed Up and Go (TUG), to measure motor performance. Secondary outcome measures included blood loss, length of procedure, length of stay and adverse events. A pre-injury FIM was measured by retrospective recall and all postoperative outcomes were assessed on postoperative day 3, at discharge, at 6 weeks, 3 months, 6 months and 12 months postoperatively. Unpaired t-tests and Chi-square tests were used for the comparison of continuous and categorical variables respectively between the Short and Long InterTAN groups. A statistically significant difference was defined as p<0.05. Our study included 71 Short InterTAN and 37 Long InterTAN patients with 31A–1 and 31A–2 intertrochanteric hip fractures. Age, sex, BMI, side, living status and comorbidities were similar between the two groups. The mean operative time was significantly lower in the Short InterTAN group (61 mins) as compared to the Long InterTAN group (71 mins)(p0.05). There were 5 periprosthetic femur fractures in the short InterTAN group versus 1 in the long InterTAN group. Non-mechanical adverse outcomes such as myocardial infarction, pulmonary embolism, urinary tract infections, pneumonia and death all had similar incidence rates between the two InterTAN groups. Both the Short and Long InterTAN patient cohorts displayed similar improvements in performance and overall function over the course of a year following intertrochanteric hip fracture fixation. The recorded operative times for Short InterTAN fixation were significantly shorter than those recorded for the Long InterTAN patients. Alternatively, a significantly higher proportion of Short InterTAN patients sustained periprosthetic femur fractures within a year of implantation as compared to the Long InterTAN group

Cervical spine fusion have gained interest in the literature since these procedures are now ever more frequently being performed in an outpatient setting with few complications and acceptable results. The purpose of this study was to assess the rate of blood transfusion after cervical fusion surgery, and its effect, if any on complication rates. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients that underwent cervical fusion surgery from 2010 to 2013. Univariate and multivariate regression analysis was used to determine post-operative complications associated with transfusion and cervical fusion. We identified 11,588 patients who had cervical spine fusion between 2010 and 2013. The overall rate of transfusion was found to be 1.47%. All transfused patients were found to have increased risk of: venous thromboembolism (TBE) (OR 3.19, CI: 1.16–8.77), myocardial infarction (MI) (OR 9.12, CI: 2.53–32.8), increased length of stay (LOS) (OR 28.03, CI: 14.28–55.01) and mortality (OR 4.14, CI: 1.44–11.93). Single level fusion had increased risk of: TBE (OR 3.37, CI: 1.01–11.33), MI (OR 10.5, CI: 1.88–59.89), and LOS (OR 14.79, CI: 8.2–26.67). Multilevel fusion had increased risk of: TBE (OR 5.64, CI: 1.15–27.6), surgical site infection (OR 16.29, CI: 3.34–79.49), MI (OR 10.84, CI: 2.01–58.55), LOS (OR 26.56, CI: 11.8–59.78) and mortality (OR 10.24, CI: 2.45–42.71). ACDF surgery had an increased risk of: TBE (OR 4.87, CI: 1.04–22.82), surgical site infection (OR 9.73, CI: 2.14–44.1), MI (OR 9.88, CI: 1.87–52.2), LOS (OR 28.34, CI: 13.79–58.21) and mortality (OR 6.3, CI: 1.76–22.48). Posterior fusion surgery had increased risk of: MI (OR 10.45, CI: 1.42–77.12) and LOS (OR 4.42, CI: 2.68–7.29). Our results demonstrate that although cervical fusions can be done as outpatient procedures special precautions and investigations should be done for patients who receive transfusion after cervical fusion surgery. These patients are demonstrated to have higher rate of MI, DVT, wound infection and mortality when compared to those who do not receive transfusion

Raised blood pressures (BP) are associated with increased cardiovascular risks such as myocardial infarction, stroke and arteriosclerosis. During surgery the haemodynamic effects of stress are closely monitored and stabilised by the anaesthetist. Although there have been many studies assessing the effects of intraoperative stress on the patient, little is known about the impact on the surgeon. A prospective cohort study was carried out using an ambulatory blood pressure monitor to measure the BP and heart rates (HR) of three consultants and their respective trainees during hallux valgus, hip and knee arthroplasty surgery. Our principle aim was to assess the physiological effects of performing routine operations on the surgeon. We noted if there were any differences in the stress response of the lead surgeon, in comparison to when the same individual was assisting. In addition, we recorded the trainee's BP and HR when they were operating independently. All of the surgeons had higher BP and HR readings on operating days compared to baseline. When the trainer was leading the operation, their BP gradually increased until implant placement, while their trainees remained stable. On the other hand, when the trainee was operating and the trainer assisting, the trainer's BP peaked at the beginning of the procedure, and slowly declined as it progressed. The trainee's BP remained elevated throughout. The highest peaks for trainees were noted during independent operating. We conclude that all surgery is stressful, and that trainees are more likely to be killing themselves than their trainers

Purpose. Triage to the intensive care unit (ICU) after elective total hip arthroplasty (THA) proves a complex medical and resource decision point. This study tested a model of pre-operative risk stratification at a tertiary, high-volume arthroplasty centre. Methods. 175 consecutive THA patients were prospectively triaged to either an ICU bed or routine post-operative floor according to admission criteria based on a prior study of 1259 THA patients. The threshold for ICU admission was >=2 risk factors: age >75 years, revision surgery, creatinine clearance <60 mL/min, prior myocardial infarction, and/or BMI >35. Primary endpoints were a reduction in unplanned admission to the ICU, as well as major complications. A pre-study power analysis demonstrated adequate patient numbers. Results. All patients were prospectively triaged and followed during the study period. After implementation of our triage model, the rate of unplanned ICU admissions dropped from 7.1 % to 2.2% (p=0.013). The as-treated odds of unplanned admission pre-versus post-intervention were 3.2 (1.2, 10.6). In an intent-to-treat analysis, the unplanned admission rate was 0.6% (p<0.001). The major complication rate fell from 12.5% to 2% with intervention, and the mortality index decreased from 4.77 to 1.62. There was only a modest increase in the total number of ICU admits (11.4% post-intervention). Conclusions. Pre-operative triage to the ICU according to selected risk factors affects a reduction in post-operative unplanned ICU admissions and major complications after elective total joint arthroplasty

We report 10 cases of supracondylar periprotheitc fractures following TKR; all were treated using a retrograde intramedualry nailing. There were 7 females and 3 males, the mean age at surgery was 76 years (range from 68–85). The average time since the primary TKR to surgery was 5.3 years (range 2–9.4). All patients had locked intramedualry nail, and knee was immobilized in a splint for few months post op. Partial weight bearing was started 2 weeks post op. There was no intraoperative complication. One patient had superficial infection, which was treated by IV antibiotics. There was no cases of septic arthritis. One patient was lost for follow up and one patient died from myocardial infarction 8 months post op. Eight patients were reviewed and assessed clinically and radiologicaly. The average range of movement in the knee was 97 (range 75–110) and all patient achieved clinical and radiological healing

The use of interspinous distraction devices should remain the subject of audit and research. They are a relatively new addition to the armamentarium of surgical treatment of lumbar spinal stenosis. The reported results are variable and there are a number of different devices available. It is recognised that there is an early failure rate with interspinous distraction devices. This is a report of the clinical results after conversion to segmental lumbar decompression following a failure of interspinous distraction procedure. 18 patients had removal of device and conversion to a standard lumbar decompression at an average of 13 months after the index procedure. There were 7 females and 11 males. The average age was 68 years (range 49-85). The two youngest patients had a decompression and instrumented fusion, the others had decompression alone. Prior to the Index procedure of stand alone interspinous distraction device the average Oswestry Disability Index (ODI) was 42 and Visual Analogue Score (VAS) leg 7.2. Prior to revision the average ODI was 42 and VAS leg 6.7. Complications: One intra operative myocardial infarction, one incidental durotomy and one post operative infection (pseudomonas isolated). At a mean of 9 months follow up the average ODI was 23 and VAS leg 2.1. The VAS back was 1.9. The walking distance was subjectively reported as 246 yards pre op and 1100 yards post procedure. There was a clinically significant improvement in all patients. A failed interspinous distraction device can be satisfactorily salvaged with a segmental lumbar decompression

Introduction and Aims: Single-stage bilateral total knee arthroplasty is an uncommon and often controversial procedure. Recent reports have refined the data relative to bilateral total knee arthroplasty and complications, which include myocardial infarction, deep vein thrombosis, pulmonary embolus and death. Method: A retrospective study of the cases of total knee arthroplasty performed by the senior authors in the last 10 years examines details of surgery and anaesthesia, pre- and post-operative management to identify the occurrence of complications. Patients also completed an Oxford Knee Score and a questionnaire relating to their experience of having a bilateral procedure. Results: While the outcomes and cost benefits of single-stage bilateral replacement are established, the risk of complications remains. This study establishes the low complication rate associated with this procedure in the senior author’s hands and documents the high patient satisfaction from it. Conclusion: The study demonstrates that, in selected patients, simultaneous bilateral knee replacement surgery can be performed with good outcomes without a definite increase in peri-operative risk

Introduction: There has been a general belief in the negative effects of increased body mass index (BMI) on the outcome of arthroplasty surgery. This study compares the complications following primary total hip replacement in obese patients. Methods: The incidence of myocardial infarction, deep vein thrombosis, pulmonary embolism, wound infection and dislocation within the 30 days postoperative period was reviewed and compared if the BMI exceeded 30. A total of 329 patients were included in this study. There were 216 cases with BMI less than 30 compared with 113 cases of BMI more than 30. Uncemented pinnacle press-fit cup on S-ROM stem was used with 28 mm head in 137 and 36 mm head in 192 cases. Results: There was no significant statistical difference in the incidence of early complications. However, in the subgroup of 28 mm head, there was significant increase in the infection rate when BMI was more than 30 (P< 0.032). Discussion: In this small study, there was no significant increase in the overall incidence of the postoperative complications in obese patients. Further studies are required to assess if implant longevity is reduced in overweight patients

Hip and knee arthroplasties are very common operations in the UK with over 70000 hip and over 80000 knee arthroplasties taking place in England and Wales in 2011. Fortunately mortality following these operations is rare. However it remains important to understand the incidence and causes of death, in order to manage risk where possible and to inform the consent process. This study aimed to evaluate the incidence and causes of death within 30 days after undergoing hip or knee arthroplasty in our unit and to highlight possible risk factors. We looked at 30 day mortality in all patients undergoing hip or knee arthroplasty in our institution between 2005 and 2011. Data on post-operative deaths was derived from the Scottish Arthroplasty Project and correlated with procedural and demographic data from our hospital Patient Administration System (PAS). The notes of all patients who had died within a period of 30 days post-operatively were reviewed to collect data on co-morbid conditions, pre-operative investigations, post-operative thromboprophylaxis and cause of death. All primary and revision knee and hip arthroplasties including bilateral procedures were included. Arthroplasty for trauma was excluded. A total of 12,243 patients underwent hip or knee arthroplasty within the study period. 59% were female and the mean age was 68 (range 21–91). During this time period the standard protocol was to use aspirin for thromboprophylaxis. Eleven patients died following surgery giving a mortality rate of 0.09%. The most common cause of death was myocardial infarction (7/11 patients). Our finding of a mortality rate of 0.09% is similar or lower to those found in previous studies. To our knowledge this is the first series of this size looking at mortality from hip and knee arthroplasty within a single centre in the UK

Single-stage bilateral total knee arthroplasty is an uncommon and often controversial procedure. Recent reports have refined the data relative to bilateral total knee arthroplasty and complications which include myocardial infarction, deep vein thrombosis, pulmonary embolus and death. Less significant complications, including post-operative ileus and pseudo-obstruction are also more common following bilateral replacement. A retrospective study of the cases of total knee arthroplasty performed by the senior authors in the last ten years, examines details of surgery and anaesthesia, pre and post-operative management to identify the occurrence of complications. Patients also completed an Oxford Knee Score and a questionnaire relating to their experience of having a bilateral procedure. While the outcomes and cost benefits of single stage bilateral replacement are established, the risk of complications remains. This study establishes the low complication rate associated with this procedure in the senior authors’ hands, and documents the high patient satisfaction from it. The study demonstrates that, in selected patients, simultaneous bilateral knee replacement surgery can be performed with good outcomes without a definite increase in perioperative risk

Cardiac and neurological functions were evaluated at the time of operation in 81 randomly selected elderly patients who had sustained a fracture of the neck of the femur. Although only one-fifth of the patients had clinical signs of senile dementia or cerebrovascular disease on admission to hospital, more than half had seriously abnormal EEGs including 12 of the 15 patients who died within six months. ECGs before operation showed that patients with signs of arrhythmia or previous myocardial infarction had a much lower survival rate than those with normal or other pathological ECG signs. Nerve conduction velocity findings proved inconclusive when correlated with survival or return home. Routine EEG and ECG examinations are of value in detecting underlying dysfunctions which may not be observable clinically on admission but are important prognostic indicators for survival or return home, and may be implicated as causative factors of fracture in the elderly

The records of 107 patients with displaced subcaptial hip fractures treated by Thompson's femoral head replacements have been reviewed to determine the mortality and certain aspects of systemic morbidity. Comparison was made with a group, matched exactly for age and sex, in which intertrochanteric fractures were treated by nail-plate fixation. The patients treated by Thompson's arthroplasty were further subdivided into two groups: one in which methylacrylic cement was used, and one in which it was not used. We found no difference in the mortality of the patients undergoing replacement arthroplasty and nail-plate fixation. Similarly there was no difference in the incidence of cerebrovascular incidents and myocardial infarction after operation. There was a higher incidence of transient cardiac failure following Thompson's arthroplasty. Hypotension during the operation occurred irrespective of whether cement was used; nor was the use of cement associated with increased mortality. However, it seems that methylacrylic cement does contribute to the cardiac failure that may occur after Thompson's arthroplasty

Major bone surgery causes damage to the bone marrow cells and destruction of blood vessels. This induces a tremendous local and systemic thrombin generation. This may trigger vascular instability during surgery that in seldom cases may be fatal in susceptible patients in particular if bone cement is implanted. The overall mortality following elective hip replacement is low since the patients are selected for the procedure and medically optimized. Following emergency hip fracture surgery the patients are substantially older, many have co-morbid conditions and the mortality is markedly higher. Vascular events dominate. Pulmonary embolism, and myocardial infarction are prominent together with pneumonia (a condition that trigger the coagulation system). Postoperatively, thrombin continues to be generated for a long time after surgery as a part of the inflammatory healing process. Vascular complications dominate and epidemiological studies have shown a general complication risk period lasting for nearly 3 months and significantly longer in subgroups. Although, mortality has decreased in recent years, morbidity continues to play an important and less focused role although with substantial health economic implications

Bilateral one-stage total knee replacement has a number of advantages. There is one operative procedure and anesthetic and overall recovery time is significantly reduced. It is a more cost effective procedure in that acute hospital stay is less and although rehabilitation time is greater in the short term overall it is less. Additionally if there is a bilateral flexion contracture present there is an inevitable loss of extension if a single knee is operated upon as this knee will assume the position of the unoperated knee. Patients greatly prefer having both knees corrected at one operative setting rather than having to have the inconvenience and pain associated with a second operative procedure at three to six months after the first one. There are potential disadvantages to a one-stage procedure. One concern has been that there is more peri-operative morbidity associated with one-stage bilateral total knee replacement. In a review of 501 patients undergoing bilateral one-stage total knee replacement at the Hospital for Special Surgery there were no peri-operative deaths, myocardial infarctions or cerebrovascular accidents. There were arrhythmias present in 5% of patients. Fat emboli were present in 3% and 2 patients (0.4%) had pulmonary emboli. The average transfusion requirement was 2.6 units and allogeneic blood was required in 42%. There were 2 deep infections, 3 hematomas and 5 patients with delayed wound healing. Average hospital stay was 7.2 days but this had decreased in the more recent patients. There was an increased incidence of major complications in patients with ASA classification 3 and with increasing age over 70 years. New data indicates peri-operative administration of hydrocortisone may mitigate lung injury as demonstrated by reduction in cytokine and desmosine levels in a randomised trial. Patient selection is important and all patients are screened pre-operatively by an internist and anesthesiologist. All patients underwent the procedure with epidural anesthesia with post-operative epidural PCA for 48 hours. All patients are discharged on warfarin and spend the operative night in the recovery room. The procedure has acceptable morbidity and great advantage in properly selected patients

Purpose: To study the results of treatment of symptomatic non-union with endoprosthesis at the Royal Orthopaedic Hospital. Methods: Between 1987 & 2005, 17patients were treated with massive endoprosthesis for non-union. We performed a retrospective review of these case notes. Results: Mean age at diagnosis was 63years (range 36–86). Location of non-union was distal femur in 9, proximal femur in 4, proximal humerus in 2, proximal tibia in 1, distal humerus in 1. The majority of the patients had received prior multiple operations before endoprosthetic surgery. Four patients had obvious infection confirmed by histology and/or microbiology prior to surgery. Endoprosthetic Reconstruction was performed as a 1 stage procedure in 13 and as a 2 stage in 4. Complications occurred in 5 patients. These included recurrence of infection in 1, persistent pain in 1, aseptic loosening in 1, periprosthetic fracture in 1 and a non ST myocardial infarction in 1. At the last follow-up, (mean 5years, range 1–18years) majority of patients achieved good range of motion and good mobility. Conclusion: We conclude that endoprosthetic replacement is a reasonable option for treatment of end-stage non-union in carefully selected patients. Adequate mobility and function can be achieved in majority of patients following such treatment

Background. In 2011 20% of intracapsular fractured neck of femurs were treated with an uncemented hemiarthroplasty in the English NHS. National guidelines recommend cemented implants, based on evidence of less pain, better mobility and lower costs. We aimed to compare complications following cemented and uncemented hemiarthroplasty using the national hospital episode statistics (HES) database in England. Methods. Dislocation, revision, return to theatre and medical complications were extracted for all patients with NOF fracture who underwent either cemented or uncemented hemiarthroplasty between January 2005 and December 2008. To make a ‘like for like’ comparison all 30424 patients with an uncemented impant were matched to 30424 cemented implants (from a total of 42838) in terms of age, sex and Charlson co-morbidity score. Results. In patients with an uncemented implant, 18-month revision (1.62% versus 0.57% (OR 2.90 [2.44–3.45], p< 0.001)), 4-year revision (2.45% vs 1.11% (OR 2.28 [1.45–3.65], p< 0.001)) and 30-day chest infection (8.14% versus 7.23% (OR 1.14 [1.08–1.21], p=0.028)) were significantly higher. Interestingly, 4-year dislocation rate was higher in cemented implants (0.60% versus 0.26% (OR 0.45 [0.36–0.55], p< 0.001). No significant differences were seen in 30-day return to theatre, myocardial infarction, cerebrovascular event or 90-day pulmonary embolus. Discussion. In this national analysis of matched patients short and medium term revision rate, and perioperative chest infection was significantly higher in the uncemented group. This supports the published evidence and national guidelines recommending cement fixation of hemiarthroplasty

Cardiovascular disease is now the leading cause of morbidity and mortality worldwide. Raised blood pressures (BP) are associated with increased cardiovascular risks such as myocardial infarction, stroke and arteriosclerosis. During surgery the haemodynamic effects of stress are closely monitored and stabilised by the anaesthetist. Although there have been many studies assessing the effects of intraoperative stress on the patient, little is known about the impact on the surgeon. A prospective cohort study was carried out using an ambulatory blood pressure monitor to measure the BP and heart rates (HR) of three consultants and their respective trainees during hallux valgus, hip and knee arthroplasty surgery. Our principle aim was to assess the physiological effects of performing routine operations on the surgeon. We noted if there were any differences in the stress response of the lead surgeon, in comparison to when the same individual was assisting. In addition, we recorded the trainee's BP and HR when they were operating independently. The intraoperative measurements were compared with their baseline readings and their stress response, assessed using the Bruce protocol. Many trends were noted in this pilot study. All of the surgeons had higher BP and HR readings on operating days compared to baseline. The physiological parameters normalised by one hour post-theatre list in all subjects. When the trainer was leading the operation, their BP gradually increased until implant placement, while their trainees remained stable. On the other hand, when the trainee was operating and the trainer assisting, the trainer's BP peaked at the beginning of the procedure, and slowly declined as it progressed. The trainee's BP remained elevated throughout. The highest peaks for trainees were noted during independent operating. We conclude that all surgery is stressful, and that trainees are more likely to be killing themselves than their trainers

Background. Intravenous and topical tranexamic acid (TXA) has become increasingly popular in total joint arthroplasty to decrease perioperative blood loss. In direct comparison, the outcomes and risks of either modality have been found to be equivalent. In addition, current literature has also demonstrated that topical TXA is safe and effective in the healthy population. To our knowledge, there is a scarcity of studies demonstrating the safety of topical TXA in high risk patient populations undergoing total joint arthroplasty or revision joint arthroplasty. The purpose of this study is to determine the safety of topical TXA in patients undergoing total or revision arthroplasty that are also on chronic anticoagulant or anti-platelet therapy. Methods. We performeded a retrospective review of patients undergoing primary and revision total hip or knee arthroplasties that received topical TXA (3g/100mL NS) from November 2012 to March 2015. All patients, regardless of co-morbidities, were included in the study population. Patients were divided into 3 groups:. Group 1: Patients without any antiplatelet or anticoagulant therapy within 90 days of surgery. Group 2: Patients receiving antiplatelet therapy (Aspirin and/or Plavix) within 90 days of surgery. Group 3: Patients receiving anti-coagulant therapy within 90 days of surgery (low molecular weight heparin, unfractionated heparin, warfarin, dabigatran, rivaroxaban, apixaban). Chart review analyzing ICD-9 and ICD-10 coding was then utilized to establish any peri-operative complications within the 30 day post-operative period in all groups. Complications amongst the groups were evaluated via chi-squared testing as well as multivariate linear regression. Review of current literature and CMS protocols were used to establish reportable peri-operative complications. Wound infections, thromboembolic events and vascular complications such as myocardial infarction, pulmonary embolism, deep venous thrombosis, stroke, aortic dissection were included. Results. During the study period, a total 1471 total joint arthroplasties were performed on 1324 patients (88.7% knee arthroplasty, 11.3% hip arthroplasty). Group 1 included 1033 patients who were not on any prior anti-platelet or anticoagulant therapy. Group 2 included 254 patients receiving chronic antiplatelet therapy 90 days prior to surgery. Group 3 included 184 patients receiving chronic anticoagulant therapy 90 days prior to surgery. No statistically significant differences were found between the groups for any of the included peri-operative complications. The most common complication occurring amongst all the groups was superficial wound infection, which occurred in a total of 60 (4.1%) patients in contrast to 18 (1.2%) patients who sustained an acute deep peri-prosthetic infection. Twenty (1.4%) patients sustained an ultrasound proven deep vein thrombosis, with the highest prevalence occurring in those patients receiving no anticoagulation prior to surgery (15/20, 75%), however this was not statistically significant following linear regression analysis. Conclusions. To our knowledge, this is the first study that demonstrates that topical tranexamic acid is safe to use in so-called high risk patients who are being treated prior to surgery with anti-platelet or anti-coagulation therapy

Background. Medical complications and death are rare events following elective orthopaedic surgery. Diagnostic and operative codes are routinely collected on every patient admitted to English NHS hospitals. This is the first study investigating rates of these events following total joint replacement (TJR) on a national scale. Methods. All patients (585177 patients) who underwent TJR (hip arthroplasty [THR], knee arthroplasty [TKR], or hip resurfacing) between 2005 and 2010 were identified. Patients were subdivided based on Charlson co-morbidity score. Data was extracted on 30-day complication rates for myocardial infarction (MI), cerebrovascular event (CVA), chest infection (LRTI), renal failure (RF), pulmonary embolus (PE) and inpatient 90-day mortality (MR). Results. The overall 90-day MR after THR was 0.44% (1116 of 256013 patients), after hip resurfacing 0.06% (17 in 27314), and after TKR 0.34% (1023 of 301850). MI rate was 0.39% (2257 of 585177). Of these 15.8% (356) died. CVA rate was 0.01% (53). Of these 32.1% (17) died. LRTI rate was 0.60% (3389). Of these 12.1% (410) died. RF rate was 0.35% (2066). Of these 13.9% (287) died. PE rate was 0.71% (4144). Of these 3.9% (161) died. For patients with no co-morbidities, no personal history of PE or DVT, and no post-operative complications (70.8% of all patients in this study, 414061 of 585177), MR was 0.09% (394 patients). Discussion. This national data analysis allows a greater understanding of mortality risk following post-operative complications. Despite the concerns regarding VTE and the high investment in prevention, fatal PE is in fact far less common than mortality after MI, LRTI and RF. This data also shows that the risk of mortality for fit patients without post-operative complications was very low

Purpose: Single anesthetic bilateral total knee arthroplasty (SABTKA) is a controversial procedure with a questionable safety profile. The purpose of this study was to determine if specific, individual preoperative medical co-morbidities can predict perioperative complications in patients undergoing SABTKA. Method: The records of all SABTKA performed between 1997 and 2007 at 1 large community hospital and 1 academic, university hospital were retrospectively reviewed. Complete demographic data, preoperative co-morbidities (cardiovascular disease, COPD, diabetes, and hypertension), and perioperative complications for 156 patients were collected and analyzed using logistic multivariate regression analysis. Comparison was made to an age, gender, and co-morbidity matched cohort of patients treated with unilateral TKA. Results: In the SABTKA group only 11% of patients had a preoperative history of cardiovascular disease yet 89% of all post operative myocardial infarctions (MI) occurred in this population (p< 0.001, Odds Ratio 57.8). Cardiovascular disease also predicted need for admission to ICU (p< 0.001, Odds Ratio 50.8), and number of days spent in the ICU (p< 0.001). In those patients without preoperative cardiovascular disease or COPD the rate of MI was only 0.64%. All differences were significant when compared to the matched unilateral TKA cohort. Age, gender, diabetes, and hypertension did not predict perioperative complications in the SABTKA cohort. Conclusion: The literature indicates there are certain populations of patients at higher risk for perioperative complications after SABTKA. This study clearly identifies a subpopulation of patients that have cardiovascular disease and are at an unacceptably high risk of perioperative MI. Cardiovascular disease should likely be considered an absolute contraindication to SABTKA

Troponin I is a widespread used blood test to confirm myocardial damage, usually attributable to myocardial infarction. Troponin tests require to be taken 12 hours after the initial event, and thus may be a potential cause for delay. SIGN and Hip Fracture Audit guidelines recommend 98% of patients obtaining surgery within 24hrs of admission. A population of 347 neck of femur patients presenting to Glasgow Royal Infirmary were assessed over a one year period. 44 (13%) Patients were identified as having a pre-operative Troponin I test. Retrospective case note review of this patient cohort who had pre operative troponin testing was undertaken to identify timing of TnI testing, admission, surgery and medical comorbidies. Time to theatre was compared with the 24hr guideline. From the cohort, 32 Patients had case notes which were located, of which 4 had no filed notes from the admission giving a 28 patient sample population. 18 (64%) had a Troponin of ‘negative’ value (<0.04 μg/l) of which the mean delay to theatre from admission was 46.4 hrs (median 44.5hrs). All 18 breached the 24hr target, 5 were delayed >48hrs. Of the 10 ‘postive’ patients, mean TnI was 0.4 and time to theatre was 85hrs (median 69hrs) with one excluded as treated conservatively. Only one patient was treated within the 24hr target (3.7% of sample group treated operatively) p=<0.001. Scottish Hip Fracture Audit shows GRI to have an overall 98.6% compliance with the 24hr target. The data presented shows significant (near complete) failure to meet the 24hr target in patients tested preoperatively for Troponin I. Almost three-quarters of these patients have normal TnI, but delay may be attributable to additional comorbidities

Fracture is the only clinically relevant aspect of osteoporosis—a major public health problem in many countries. The strongest predictor for a new fragility fracture is a previous one. For instance, a patient with one osteoporotic vertebral compression fracture has about a seven-fold increased hip fracture risk; a patient with two compression fractures a 14-fold hip fracture risk. Today, we have evidence based and efficient osteoporosis drugs as well as non-pharmacologic methods for fracture prophylaxis. In risk group patients it often is possible to halve the fracture risk. The orthopaedic surgeon is the first and sometimes the only doctor a fracture patien sees. Therefore, as orthopaedic surgeons, we have a great opportunity—and indeed an onus—to identify patients with increased fracture risk, and to do something about it. Imagine patients with myocardial infarction or stroke discharged from hospital without blood pressure control or having a biochemical profile taken? Such negligence is, alas, not uncommon for patients with fragility fractures. We must think in terms of absolute fracture risk, and implement today’s evidence based knowledge. Secondary prophylaxis should be an integrated part in fracture treatment. And this calls for a multidisciplinary and multiprofessional teamwork including surgeons, geriatricians, endocrinologists and general practitioners, as well as nurses, physiotherapists and a wide range of other paramedical specialists. Such “fracture chains” will reduce the number of unnecessary and preventable injuries and will have a great impact in terms of cost and suffering. This symposium will give an overveiw of fracture-preventing strategies

Total knee arthroplasty revisions (TKAR) are increasing in incidence. These complex and demanding procedures are typically associated with a higher complication rate than primaries. We report on the actual complications encountered in a prospective study of TKAR patients to determine the current nature and incidence of these problems. 230 consecutive patients undergoing TKAR were enrolled to our database and had information on demographics, comorbidities, outcomes (WOMAC and SF-36) and complications recorded. Baseline information and data from 2 month, 6 month and 1 year follow up was collated. Mean patient age was 68.0 and clinical outcomes scores showed significant improvements for function, stiffness and pain at all points of follow-up. The total number of complications was 131 in 97 (42.2%) patients (48 by 2 months, 46 at 6 months and 32 at 1 year). Systemic complications comprised 41 of these, many being relatively minor. There were no deaths, 4 deep vein thromboses and 3 myocardial infarctions. The majority of complications (90) were local, including 2 patellar dislocations, 3 periprosthetic fractures, 3 peroneal nerve injuries, 2 ‘late’ patellar tendon ruptures and 1 patellar avascular necrosis, 9 wound hematomas, and a substantial rate of 21 superficial or deep wound infections. Although patients experience significant improvement in function, activity and pain following TKAR, there is a considerable incidence of complications up to 1 year following TKAR. This is important in terms of resources, patient counseling and also in identifying and instituting preventive measures where possible in order to improve outcomes for these patients

Background. Medical complications and death are rare events following elective orthopaedic surgery. Diagnostic and operative codes are routinely collected on every patient admitted to hospital in the English NHS (hospital episode statistics, HES). This is the first study investigating rates of these events following total joint replacement (TJR) on a national scale in the NHS. Methods. All patients (585177 patients) who underwent TJR (hip arthroplasty [THR], knee arthroplasty [TKR], or hip resurfacing) between January 2005 and February 2010 in the English NHS were identified. Patients were subdivided based on Charlson co-morbidity score. HES data in the form of OPCS and ICD-10 codes were used to establish 30-day medical complication rates from myocardial infarction (MI), cerebrovascular event (CVA), chest infection (LRTI), renal failure (RF), pulmonary embolus (PE) and inpatient 90-day mortality (MR). Results. The overall 90-day MR after THR was 0.44% (1116 of 256013 patients), after hip resurfacing 0.06% (17 in 27314), and after TKR 0.34% (1023 of 301850). MI rate was 0.39% (2257 of 585177). Of these 15.8% (356) died. CVA rate was 0.01% (53). Of these 32.1% (17) died. LRTI rate was 0.60% (3389). Of these 12.1% (410) died. RF rate was 0.35% (2066). Of these 13.9% (287) died. PE rate was 0.71% (4144). Of these 3.9% (161) died. For patients with no co-morbidities, no personal history of PE or DVT, and no post-operative complications (70.8% of all patients in this study, 414061 of 585177), MR was 0.09% (394 patients). Discussion. This national data analysis allows a greater understanding of mortality risk following post-operative complications, and provides robust information for the consenting process. It also shows that the risk of mortality for fit patients without post-operative complications was very low - a group which is thought to have a high rate of ‘silent’ fatal PEs

Objective: To analyse the incidence and gravity of reported complications that arise in spinal surgery and assess the comparative safety, or otherwise, of Endoscopic Laser Foraminoplasty. Design: Prospective independently analysed study of complications arising during the six weeks following Endoscopic Laser Foraminoplasty was correlated and compared to a meta-analysis of reported data on complications in conventional spinal surgery. Subjects: Nine hundred and fifty-eight procedures performed on 716 patients. Outcome measures: Occurrence of complications. Results: The cohort integrity of operative and review records at six weeks after surgery was 100%. Twenty four complications occurred in 23 patients: nine cases of discitis (one infective) (0.9%), one dural tear (0.1%), one deep wound infection (0.1%), two patients suffered a foot drop (one transient) (0.2%), one myocardial infarction (0.1%), one erectile dysfunction (0.1%) and one post operative panic attacks (0.1%). MRI later demonstrated eight residual disc herniations (0.8%). The overall surgical complication rate was 1.6%. Meta-analysis of conventional spinal surgery reported overall complication rates for fusion (11.8%), decompression (7.6%), discectomy (6.0%) and chemonucleolysis (9.6%). Conclusions: The complication rate of Endoscopic Laser Foraminoplasty is significantly lower than that reported following conventional spinal surgery (P < 0.01)

Pre-operative co-morbidities such as known coronary artery disease have commonly deemed a patient at ‘high risk’ for primary elective Total Hip Arthroplasty (THA). We prospectively collected data on 1744 patients who underwent primary elective THA between 1998 and 2004. 273 had a history of cardiac disease defined as a previous hospital admission with a diagnosis of angina pectoris or myocardial infarction. 594 patients had hypertension defined as that requiring treatment with antihypertensives. We also had data on pre-operative age, sex and body mass index (BMI). There was no statistically significant increase in early mortality at 3 months with a history of cardiac disease or hypertension and this remained so when adjusting for the other factors in a multivariate analysis. Sex or BMI also did not have a statistically significant effect on the risk of death within 3 months. Increasing age was the only significant risk factor for early mortality (P<0.001). Longer term mortality at 2 and 5 years in relation to these factors was also examined. Statistical analysis revealed that coronary history now showed a highly significant association (P<0.001) with long term mortality, in patients who survived more than 3 months. 95% confidence intervals for percentage mortality at 5 years were 9.7 - 21.7 with a cardiac history compared to 4.8 - 8.8 without a cardiac history. This remained significant (P=0.002) when adjusted for the other factors. Hypertension continued to have no effect, nor did BMI. Age remained a significant risk factor. Females had a slightly lower long term death rate than males, following THA. The overall long term mortality following THA was less than expected from the normal population, even in the subgroup with a coronary history. This study will assist clinicians when advising patients seeking primary elective THA, who have one of these common risk factors

This study aims to assess prospectively whether measurement of perioperative Troponin T is a useful predictor of potential morbidity and mortality in patients undergoing surgery for fractured neck of femur. All patients aged 65 years and over presenting with a fractured neck of femur over a 4-month period were initially included. Exclusion criteria were renal failure, polymyositis and conservative fracture management. Troponin T levels were measured on admission, day 1 and 2 post-surgery. According to local protocol, a level of >0.03ng/mL was considered to be raised. Outcome measures adverse were cardiorespiratory events (myocardial infarction, congestive cardiac failure, unstable angina, major arrhythmias requiring treatment and pulmonary embolism), death and length of inpatient stay. 108 patients were recruited after application of the exclusion criteria. 42 (38.9%) showed a rise in Troponin T >0.03ng/mL in at least one sample. Of these, 25 (59.5%) sustained at least outcome complication, as opposed to 7 (10.6%) from the group with no Troponin T rise (p<0.001). The mean length of stay was 25.7 days for patients with elevated Troponin T levels, compared with 18.3 days in the normal group (p<0.012). There were 9 deaths in the raised Troponin group (21.4%), and 5 (7.6%) in the group with no rise (p<0.05). The principal causes of early death after hip fracture surgery are cardiac failure and myocardial infarction. Troponin T is a sensitive enzymatic marker of myocardial injury. The association between raised Troponin and hip fractures has not previously been made. In our series, 38.9% showed a perioperative Troponin rise. This was significantly associated with increased morbidity, mortality and longer hospitalisation. Many hip fracture patients appear to be having silent cardiorespiratory events, contributing significantly to perioperative morbidity. We recommend measurement of Troponin levels in all such patients to identify this risk and initiate appropriate treatment

Introduction. Typical UK patients spend 5–7 days in hospital following total hip replacement (THR). Decreasing length of stay (LOS) increases throughput and reduces cost. We have developed a short stay THR programme (SSP), which has been used in all patients since May 2006; we present the first 100. Methods. Every patient undergoing THR is included in the dataset. All attend ‘bone school’ before admission, with talks and individual assessments by the senior sister, physiotherapist and occupational therapist. Medical concerns are discussed with an anaesthetist. Patients receive training with crutches; crutches are provided for home practice. All receive an uncemented Corail-Pinnacle THR via piriformis-sparing mini-posterior approach. ‘Low dose’ spinal plus light general anaesthesia provides sensory block whilst retaining motor function; painfree fully weightbearing mobilisation is predictably achieved within four hours. Following radiograph and haemoglobin check next morning, patients are discharged on meeting specific nursing/physiotherapy criteria. Those within 20 miles receive outreach follow-up. Follow-up assessment is undertaken using SF36, Visual Analogue, Merle d'Aubigné-Postel and Oxford Hip Scores. Results. Mean age was 65 years (25–91), mean BMI 28.7 (19–43), mean ASA 1.97 (1–3). Major complications were: one dislocation, one deep infection, one myocardial infarction. Several more minor complications occurred. Mean LOS was 1.99 nights (1–19). One patient was readmitted with wound ooze. No association existed between LOS and ASA/age. 82 patients remain under follow-up, (mean 37.8 months, range 36–61). Seven have died; four underwent revision; seven have moved away or been lost. 97% remain quite or very satisfied. Discussion. We believe our LOS to be amongst the shortest in the country, with favourable clinical results. The SSP succeeds by involving all team-members throughout, and managing patient expectation. At a time of limited healthcare resources we propose that our SSP is totally reproducible, and could readily be established elsewhere with similar benefits

Background: Total joint arthroplasty (TJA) is a successful procedure. With the demographic tendency towards an elderly society and a relatively high prevalence of arthritis, the number of joint replacement in the US will increase dramatically in the upcoming years. The orthopaedic surgeons need to be aware of the various types of complications in the early hospital setting associated with elective TJA. Methods: This prospective study reviewed the systemic and local early complications occurring after 13133 TJA which included 7,438 hip arthroplasties (6,010 primary and 1,428 revisions) and 5,695 knee replacements (4,944 primary and 751 revisions). A standardized and detailed form intended to capture all medical and orthopedic complications was devised, plus a full-time research fellow was dedicated to this study. The hospital course of every patient was followed on a daily basis closely. The circumstances leading to the complications and the details of the therapeutic intervention for each complication were recorded. Results: In general the incidences of complications were higher following TKA compared to THA. There was 26(0.19%) deaths in the cohort that occurred within 10 days after surgery. 329 major (life threatening) complications occurred in the cohort that included myocardial infarction (36), hypotensive crisis (11), pulmonary embolus (145), tachyarrhythmia (93), pulmonary edema (10), acute renal failure (24), stroke (6), bowel obstruction or perforation (3), and pneumothroax (1). There were 37 major local complications. 301 (91%) of these complications occurred within 4 days of index surgery. There were 453 minor systemic complications, mostly related to anemia, and 99 minor local complications in this cohort. Conclusions: Total joint arthroplasty despite its success can be associated with serious and life threatening complications. The introduction of MIS surgery and the potential for very early discharge of patients undergoing arthroplasty needs to be scrutinized in light of these findings

Epitheloid haemangioendothelioma is a rare tumour of vascular origin. It is characterised by the appearance of epitheloid endothelial cells and occurs typically in soft-tissue, skin, and liver. Less frequently it is found in bone. The tumour is more often located in the long bones of the lower extremities, and the pelvis than in the upper extremities, vertebral column, and flat bones. The lesion nearly affects all age groups and there is a male predilection. Case 1: A 71-year old woman had pain in the area of her right hip after a downfall. X-ray showed a lucency of the cortical substance of the right femur. Scintigraphy showed a cortical lesion, oedema of the bone-marrow and an involvement of soft-tissue. Carcinoembryonic antigen, CD 31, and CD 8 were positive. An open biopsy verified an epitheloid haemangioendothelioma. Staging was negative. A wide resection of the proximal femur and reconstruction with a tumour-prosthesis were performed. Four months later the patient had osteolytic metastases of os ilium, os pubis, acetabulum and in the fifth lumbar vertebra. The patient died 8 months after the wide resection of the tumour because of myocardial infarction. Case 2: An epitheloid haemangioendothelioma of the liver was diagnosed in a 21-year old male patient. Twelve years after the primary tumour the patient had osteolyses of the first cervical vertebra, manubrium sterni, and ribs. An open biopsy verified the metastatic spread. Local radiotherapy was performed. Furthermore the patient developed a destruction of processus spinosus and a pathologic fracture of first thoracic vertebra. The patient died of metastatic disease 2 years later or 14 years after the initial diagnosis. Epitheloid haemangioendothelioma of bone is a rare tumour and the diagnosis is quite difficult. Metastatic rate is about 20–30% and mortality about 10–20%. As presented in our cases bone involvement could either be attributed to primary haemangioendotheliomas of bone or to metastases of non-osseous forms. As in our cases it has been reported, that predicting prognosis is difcult, however nuclear atypia, mitotic activity, spindling of cells, and necrosis have been reported as negative prognostic factors

Introduction. Following National patient safety alert on cement use in hip fracture surgery, we investigated the incidence and pattern of 72 hours peri-operative mortality after hip fracture surgery in a District General Hospital. Methods. We reviewed all patients who had hip fracture surgery between 2005-April, 2010. We recorded demographic variables, type of fracture, implant used, medical co-morbidity, seniority of operating surgeon and anaesthetist, peri-operative haemodynamic status, time and cause of death. Results. Over a 64 month period 15 cases were identified. Peri-operative death (PAD) was 1% (15/1402). 4/15 patients died intra-operatively. PAD was highest following Exeter Trauma Stem (ETS) implantation (5/85, 6%) and nil following Bipolar arthroplasty, Austin-Moore arthroplasty (AMA) or Cannulated screw fixation. PAD following total hip arthroplasty was 4% (1/25), Thompson's hemi-arthroplasty 2% (3/191), and Dynamic Hip Screw fixation 1% (6/695). Overall mortality after cemented implant was 2%. ETS implantation led to significantly increased peri-operative mortality compared to AMA (p=0.004). Operations were performed by both trainees (12) and Consultants (3). Both trainees (9) and Consultants (6) anaesthetised the patients. None of the patients belonged to ASA I or II (ASA III 6 and IV 9). All patients had significant cardio-vascular or pulmonary co-morbidity (Ca Lung 2, pulmonary fibrosis 1, end stage COAD 1, AF 6). Cemented implant insertion was followed by immediate haemodynamic collapse and death in 4/15, intra-operative haemodynamic instability in 1/15 and peri-operative instability in 5/15. Post-mortem was performed in 5/15: 2/5 were Pulmonary Embolism (PE), 2/5 bronchopneumonia and 1/5 Myocardial infarction (MI). 4/15 had suspected MI and 1/15 suspected PE. Conclusion. There was 1% risk of peri-operative death after hip fracture surgery. This risk was increased following cemented hemiarthroplasty and highest after ETS implantation. Risk was exacerbated in patients with pre-existing cardiovascular morbidity and independent of the seniority of the surgeon or the anaesthetist

In 1997 the “step-less” SL Plus (Endoprothetik, Rotkreuz, Switzerland) cementless total hip arthroplasty was introduced to our unit. During the passed 12 months, a retrospective study has been performed in order to evaluate the clinical and radiographic results of this arthroplasty. The preliminary results of the first 50 patients to have completed the clinical and radiographic follow-up have been evaluated. Of the 50 patients, 56 primary total hip arthroplasties were performed, in all cases the SL Plus stem was used. In 52 cases the cementless Doetz acetabular cup, made by the same manufacturer, was used. The other 4 acetabular components were: 2 long stemmed cementless components for developmental dysplasia, 1 standard cementless cup and 1 cemented cup, made by other manufacturers. All patients were reviewed clinically and radiographically. The mean follow-up time was 3 years, range 2 – 5 years. The mean Harris Hip Score was 90 (37 – 100). Patient satisfaction was: 98% satisfied, 2% dissatisfied (p < 0.001). Radiographic assessment demonstrated that all 52 (100%) Doetz acetabular cups osseointegrated, with 53 (95%) acetabular cups osseointegrating in total (p < 0.002). Of the SL Plus stems, 44 (79%) osseointegrated (p < 0.002). The following post-operative complications were observed: 2 dislocations, 2 superficial wound infections, 1 myocardial infarction, 1 sciatic nerve palsy and 1 deep vein thrombosis. The overall complication rate is high at 13%, but with no implant related failures. Nevertheless, the preliminary clinical and radiographic results of the SL Plus stem and Doetz acetabu-lar cup total hip arthroplasty are encouraging

Preoperative co-morbidities such as known coronary artery disease have commonly deemed a patient at ‘high risk’ for primary elective Total Hip Arthroplasty (THA). We prospectively collected data on 1744 patients who underwent primary elective THA between 1998 and 2004. 273 had a history of cardiac disease defined as a previous hospital admission with a diagnosis of angina pectoris or myocardial infarction. 594 patients had hypertension defined as that requiring treatment with antihypertensives. We also had data on preoperative age, sex and body mass index (BMI). There was no statistically significant increase in early mortality at 3 months with a history of cardiac disease or hypertension and this remained so when adjusting for the other factors in a multivariate analysis. Sex or BMI also did not have a statistically significant effect on the risk of death within 3 months. Increasing age was the only significant risk factor for early mortality (P< 0.001). Longer term mortality at 2 and 5 years in relation to these factors was also examined. Statistical analysis revealed that coronary history now showed a highly significant association (P< 0.001) with long term mortality, in patients who survived more than 3 months. 95% confidence intervals for percentage mortality at 5 years were 9.7 – 21.7 with a cardiac history compared to 4.8 – 8.8 without a cardiac history. This remained significant (P=0.002) when adjusted for the other factors. Hypertension continued to have no effect, as did BMI. Age remained a significant risk factor. Females had a slightly lower long term death rate than males, following THA. The overall long term mortality following THA was less than expected from the normal population, even in the subgroup with a coronary history. This study will assist clinicians when advising patients seeking primary elective THA, who have one of these common risk factors

This study aims to assess prospectively whether measurement of peripoperative Troponin T is a useful predictor of potential morbidity and mortality in patients undergoing surgery for fractured neck of femur. All patients aged 65 years and over presenting with a fractured neck of femur over a 4-month period were initially included. Exclusion criteria were renal failure, polymyositis and conservative fracture management. Troponin T levels were measured on admission, day 1 and 2 post surgery. According to local protocol, a level of > 0.03ng/mL was considered to be raised. Outcome measures adverse were cardiorespiratory events (myocardial infarction, congestive cardiac failure, unstable angina, major arrhythmias requiring treatment and pulmonary embolism), death and length of inpatient stay. 108 patients were recruited after application of the exclusion criteria. 42 (38.9%) showed a rise in Troponin T > 0.03ng/mL in at least one sample. Of these, 25 (59.5%) sustained at least outcome complication, as opposed to 7 (10.6%) from the group with no Troponin T rise (p< 0.001). The mean length of stay was 25.7 days for patients with elevated Troponin T levels, compared with 18.3 days in the normal group (p< 0.012). There were 9 deaths in the raised Troponin group (21.4%), versus 5 (10.6%) in the group with no rise (p< 0.05). The principle causes of early death after hip fracture surgery are cardiac failure and myocardial infarction. Troponin T is a sensitive enzymatic marker of myocardial injury. The association between raised Troponin and hip fractures has not previously been made. In our series, 38.9% showed a perioperative Troponin rise. This was significantly associated with increased morbidity, mortality and longer hospitalisation. Many hip fracture patients appear to be having silent cardiorespiratory events, contributing significantly to perioperative morbidity. We recommend measurement of Troponin levels in all such patients to identify this risk and initiate appropriate treatment

Aim To assess the outcome of ankle fractures in diabetic patients. Method The case notes and X-rays of 39 patients with diabetes, who had sustained ankle fractures between 1994–2003, were retrospectively analysed. Results There were 23 females and 16 males with mean age of 66 years in females and 51 years in males. The fracture was the result of a twisting injury in 37 of 39 patients. The average duration of diabetes prior to the fracture was 9.6 years. Thirty per cent of patients had systemic complications. Twenty patients had insulin dependent and 19 had non-insulin dependent diabetes. Fractures were on the left side in 21 patients. One patient had a Gustilo grade 2 fracture. Two had a single malleolar fracture, 28 had bi-malleolar fractures and the remaining nine had tri-malleolar fractures. Talus shift was present in 26 cases. The average time to surgery is 3.8 days. The mean ASA grade is 2.3. Twenty-one patients were managed operatively, of which seven had an infection. One patient underwent amputation. One had post-operative myocardial infarction. Nineteen were managed conservatively and in this group, four patients had infected pressure sores from the plaster, of which two needed plastic surgery care. One was managed with external fixator and developed osteomyelitis, and persistent talus shift and non-union. Three patients died within 2 years of fracture due to diabetes-related complications. Union was achieved in 36 cases and 30 of the patients walked independently after union. Conclusion There is a high complication rate following surgery for fractures of the ankle in diabetic patients, but conservative treatment also carries a significant risk because poor skin condition can lead to pressure sores while in plaster and these may need major plastic interventions

Introduction: The principle causes of early death after hip fracture surgery are cardiac failure and myocardial infarction. Troponin T is a sensitive and specific enzymatic marker of myocardial injury. This study aims to assess prospectively whether Troponin T may be used as a predictor of morbidity and mortality in admissions with fractured neck of femur. Methods: All patients aged 65 years and over presenting with a fractured neck of femur over 4 months were included. Exclusion criteria of polymyositis, renal failure and conservative fracture management were applied. Troponin T levels were measured on admission, and days 1 and 2 post surgery. According to local protocol, a level of > 0.03ng/mL was considered to be raised. Outcome measures were defined as adverse cardiorespiratory events (myocardial infarction, congestive cardiac failure, unstable angina, major arrhythmias requiring treatment and pulmonary embolism), death and length of inpatient stay. Results: 108 patients were recruited over the 4 months. 42 (38.9%) showed a rise in Troponin T > 0.03ng/mL in at least one sample. Of these, 25 (59.5%) sustained at least one of the outcome complications including death, as opposed to 7 (10.6%) from the group with no Troponin rise (p< 0.001). The mean inpatient stay was 25.7 days for patients with elevated Troponin T levels, compared with 18.3 days in the normal group (p< 0.012). There were 9 deaths in the raised Troponin group (21.4%), and 5 (10.6%) in the group with no rise (p< 0.05). Discussion: The association between raised Troponin and hip fractures has not previously been made. Many patients appear to be having silent cardiorespiratory or related events, which may be a significant cause of perioperative morbidity and mortality. We propose measurement of Troponin levels as part of the standard perioperative screening for hip fracture patients to identify this risk and initiate appropriate treatment measures

The gamma interlocking nail, designed combining the advantages of the sliding hip screw with the intramedullary nail, was initially introduced for the management of unstable proximal femoral fractures. However the unacceptably high incidence of lateral femoral shaft fractures led to the development of the long gamma nail. This is the result of a prospective study of the use of the long gamma nail in 35 patients over a 7 year period till March 2000. The mean age of the patients was 69.9 years. There were 13 men and 22 women. All but two of the fractures had a subtrochanteric component. Ten were pathological fractures. An identical size of nail was used in all cases. Elderly patients were permitted to mobilise without restriction, whereas partial weight bearing was imposed on the younger patients till some signs of radiological healing. Patients were reviewed at a hip fracture clinic. Mean clinical follow up was 381 days and radiological follow up was 244 days. Mean hospital stay 22 days. The post operative mortality at 30 days was 20%, rising to 45% at one year. General complications that occurred were pneumonia – 3, fat embolism – 1, myocardial infarction – 1, and GI bleed – 1. Four cases had superficial wound infection, which resolved with oral antibiotics. Fracture related complications occurred in 4 cases. These were intra-operative femoral shaft fracture – 1, fracture at tip of nail – 1, nail breakage – 2. All went on to heal after exchange nailing. The long gamma nail does not appear to have reduce the post-operative incidence of femoral fractures, which is most likely related to the large size of the distal locking screws and stress concentration at the tip of the nail. The two cases of nail breakage appear to reflect metal fatigue failure in the setting of delayed union in younger patients

As our population ages, the incidence of hip fractures per annum is increasing rapidly. Within this patient group are an increasing number of very elderly (over 90 years old). These patients present many challenges to the clinician, both in terms of medical co-morbidities and orthopaedic complications. While the mortality and morbidity of hip fractures in general are well recognised, this study looked exclusively at the outcome in these very elderly patients following admission. We reviewed 100 patients admitted between May 2000 and June 2002. The average age of our patient group was 92.5 years, 18% were male and 82% female. 60% were resident in nursing homes prior to admission, 26% lived with their families and 14% lived alone in the community. 56% of the fractures suffered were intertrochanteric, 40% were intra-capsular and 4% sub-trochanteric. Following admission, these patients waited on average 1.5 days before undergoing surgery, the predominant cause for pre-operative delay being maximisation of pre-operative medical condition. Median pre-operative ASA score was three. The method of anaesthesia used was spinal in 78% and general in 22%. 64% of the group underwent internal fixation and 34% had a hemiarthroplasty. Two patients were deemed unfit to ever undergo surgery. Following surgery, mean in-hospital stay was 9.3 days. There were 8 in-patient post-operative mortalities. Major post-operative morbidities occurred in 8% and included: 3 myocardial infarctions, 2 acute onset cardiac failure and 1 prosthetic dislocation. 11% of patients required a blood transfusion. 25% of the patients died within forty days of surgery, however, 50% of the patients were still alive 126 days post-op. Overall, the mean survival was 195 days. Post-discharge morbidity included two patients who had failure of internal fixation and 8 patients with severe immobility. We conclude that hip fracture surgery in the nonagenarian population is as well tolerated as surgery in younger patients. Careful pre-operative assessment and medical maximisation combined with prompt surgical intervention yielded a good outcome and return to pre-injury status for most patients

Total knee arthroplasty has been associated with substantial blood loss in the perioperative period necessitating a substantial risk for blood transfusions. There are various methodologies utilized to decrease postoperative anemia and minimize the need for allogeneic blood transfusions. These include autologous pre-donation, the use of erythropoietin and the use of perioperative cell salvage. Although all of these are successful in decreasing postoperative anemia, there is still a significant risk of allogeneic blood transfusions in the postoperative period. This is a retrospective review of a consecutive series of total knee replacements investigating blood loss and the need for postoperative blood transfusions utilizing MIS surgical techniques and Symphony (tm) platelet gel as the sole means of blood conservation. PATIENT DEMOGRPAHICS. Between January 1, 2005 to December 31, 2005, 83 total knee arthroplasties were performed in a variety of community hospitals by a single orthopedic surgeon. The mean age was 64 years (SD 11.6, range 28-90) and the mean BMI was 34.1 (SD 7.6, range 21.3 to 53.4). 71% of the patients were females and 29% males. All patients, regardless of deformity, age or size, had a quad sparing MIS total knee arthroplasty performed utilizing cemented posterior stabilized components and all patellae were resurfaced. No patients pre-donated any blood products or had erythropoietin and no drains were utilized postoperatively. All patients had application of Symphony (tm) platelet gel prior to the interoperative release of the tourniquet. All patients received Coumadin on the day of surgery and were managed for four weeks postoperatively to keep their INR approximately 2.0. RESULTS. The mean preoperative hemoglobin was 14 (SD 1.2, range 10.7 to 16.6). The average postoperative hemoglobin was 10.0 (SD 1.1, range 8.0 to 14.2). The average drop in hemoglobin was 4.0 with a SD of 1.1. A total of two patients were transfused in this series of 83 patients for a total transfusion rate of 2.4%. The average length of stay was 3.4 days with the SD of 3.7. No patients suffered a CVA, myocardial infarction or pulmonary embolus in the two-month postoperative period. CONCLUSIONS. The results show that even utilizing MIS surgical techniques and Symphony (tm) platelet gel, there is still substantial blood loss in patients undergoing unilateral total knee arthroplasty utilizing cemented components with a mean drop of hemoglobin of four grams or 20% of their mean preoperative hemoglobin. However, in spite of significant loss of hemoglobin, most patients tolerated the postoperative anemia very well and there were no complications in this series related to anemia and this did not prolong their length of stay, which was an average of 3.4 days. Only a very low percentage of patient's in this series required a postoperative transfusion (2.4%). This report supports the continued use of MIS surgical techniques along with Symphony (tm) platelet gel to minimize the need for postoperative transfusions in total knee arthroplasties

Objective: To analyse the incidence and gravity of reported complications that arise in spinal surgery and assess the comparative safety, or otherwise, of Endoscopic Laser Foraminoplasty. Methods: The Spinal Foundation, Rochdale, has performed 958 Endoscopic Laser Foraminoplasty procedures and holds a comprehensive database of the results of all operations carried out in this manner. The records of these procedures provided the basis for a comparison of the safety of Endoscopic Laser Foraminoplasty to that found for other spinal surgical techniques as reported in the literature. Nine hundred and fifty eight procedures have been performed on 716 patients. Complications that arose during the operation and the postoperative phase of six weeks following the procedure were elicited from patient records. This data was correlated and compared to a meta-analysis of randomised controlled trial data available on complications arising during and after conventional spinal surgery. The ‘SPSS’ and ‘CIA’ statistical packages were used to draw conclusions as to the safety of endoscopically assisted laser spinal surgery. Results: The cohort integrity of operative and review records at six weeks after surgery was 100%. In 958 ELFs performed, 24 complications occurred in 23 patients. There were nine cases of discitis (one infective) (0.9%), one dural tear (0.1%), one deep wound infection (0.1%), two patients suffered a foot drop (one transient) (0.2%), one myocardial infarction (0.1%), one erectile dysfunction (0.1%) and one patient who developed panic attacks post-operatively (0.1%). This amounts to an overall surgical complication rate of 1.6%. MRI follow up of clinically symptomatic patients highlighted eight residual disc herniations (0.8%). Meta analysis of randomised controlled trials of conventional spinal surgery for adult onset degenerative disc disease and/or sciatic pain reported overall complication rates for fusion (11.8%), decompression (7.6%), discectomy (6.0%) and chemonucleolysis (9.6%). Conclusions: The complication rate of Endoscopic Laser Foraminoplasty is shown to be significantly lower than that reported following conventional spinal surgery (P < 0.01). From these results it must therefore be concluded that ELF as a treatment for chronic low back pain and sciatica presents less risk to a patient than conventional methods of spinal surgery

Purpose: MetS has been shown to be a risk factor for chronic diseases such as cardiovascular diseases (CVD), including myocardial infarction and stroke, and dementia. Moreover, the risk factors that make up the MetS (central obesity, diabetes, high blood pressure, and dyslipidemia) have also been demonstrated to have independent relationships to degenerative joint disease. The relationship between the metabolic factors and spine OA have been examined by few, however the predictive value of MetS on the incidence or prevalence of this disease has not been studied. In this study, we asked whether the prevalence of spinal OA increases with the number of MS risk factors. Method: We reviewed data from a single surgeon, high volume, spine surgery practice between the years of 2002–2007. Demographic data including the components of the MetS risk factors were collected. Prevalent severe OA was defined as degenerative spondylolisthesis or cervical or lumbar stenosis causing neurologically based symptoms, and early OA as those with lumbar and cervical spondylosis causing axial pain only. Logistic regression modeling was used to determine the odds (adjusted for age and sex) of having severe spine OA with an increasing number of the MetS risk factors. Results: In our cohort of 1502 patients, there were 839/1502 (55.9%) patients defined as severe spinal OA and 663/839 (44.1%) patients with early OA. Those with severe spinal OA were significantly older, with a greater percentage of females, and had a greater BMI than those with early spinal OA (p < .05). The prevalence of severe spinal OA varied across groups defined by the number of MetS risk factors: 353/748 (47.2%) in those with 0 MetS risk factors, 236/392 (60.2 %) in those with 1 MetS risk factors, 148/228 (64.9 %) in those with 2 MetS risk factors, 76/104 (73.1 %) in those with 3 MetS risk factors, and 26/30 (86.7 %) in those with all 4 MetS risk factors. The overall prevalence of MetS was 30/1502 (2.0%), 26/839 (3.1%) in the severe OA group and 4/663 (0.6%) in the early OA group.(p= .001) Logistic regression modeling showed the odds of having severe spinal OA increased with an increasing number of MetS risk factors relative to having no MetS risk factors. Those patients having defined as MetS had almost a 4 times greater odds of having severe spinal OA as compared to those with no MetS risk factors, adjusted for age and gender [OR 3.9,(1.4, 11.6), p= .01]. Conclusion: The components of MetS are more prevalent in those with severe spinal OA causing neurological symptoms compared to those with spondylosis causing axial pain. Future work should examine for an association between MetS and incident OA

Background: Data on thromboembolic complications (TEC) following major orthopaedic surgery are generally obtained retrospectively from registries or prospectively from large industry-sponsored international multicentre trials. However, the results may differ from those observed in unselected patients in routine operations performed by orthopaedic surgeons. The purpose of the ESMOS study was to describe the number and time of onset of serious symptomatic arterial and venous TEC within 90 days after surgery in an unselected population of patients undergoing total hip replacement (THR). Patients and methods: A total of 500 (430 primary THR and 70 revision THR) consecutive patients were included in the study performed between January 2004 and May 2005 in Frederiksborg County (Denmark). They were to be followed for 90 days after surgery. Patients were interviewed before surgery for medical history and on days 5 (while in hospital) and 90 (by telephone call) for signs and symptoms of acute myocardial infarction (AMI), pulmonary embolism (PE), deep-vein thrombosis (DVT), transitory cerebral ischemia (TCI)/stroke and retinal vein thrombosis (RVT). The validity of the events was confirmed using files from hospital, general practitioner and international criteria. Results: Overall, 498 patients were followed-up for 90 days, 2 patients having withdrawn consent. In-hospital pharmacological thromboprophylaxis was performed in 499 patients. Twenty-four patients (4.8%) experienced at least one serious TEC up to day 90: 2 (0.4%) patients died from surgical-related complications (no autopsy was performed); 1 (0.2%) patient experienced AMI, 5 (1.0%) had PE, 10 (2.0%) DVT, 4 (0.8%) TCI, and 2 (0.4%) RVT. Moreover, 2 patients experienced two TEC: AMI followed by TCI in a first patient, PE and TCI in a second patient. The first event occurred up to day 5 in 9 patients (38%) and after day 5 in 15 patients (62%). Five patients (1%) had clinically relevant bleeding complications: 3 patients had a single, minor, upper gastrointestinal bleeding episode while in hospital, one patient developed a huge expanding haematoma at the operation site treated with hip spica and another patient a peritoneal haematoma leading to re-operation. Conclusion: This study performed in an unselected population clearly shows that THR still results in serious TEC in spite of a wide use of modern anaesthesia techniques, thrombosis prophylaxis and early mobilisation. In the future, we need to better identify at-risk patients in order to optimise their management, in particular post-discharge care, and reduce the risk of serious TEC

Depression and anxiety are widely prevalent amongst patients suffering from chronic diseases including osteoarthritis. National Institute for Clinical Excellence (NICE) guidelines recommend vigilance and routine screening in such chronic disease patients, and a recent King's Fund report found depression causes considerable expense to the NHS, with £1 for every £8 spent on chronic disease spent on patients mental health, costing between £8-13 billion annually. Depression increases length of hospital stay, and poorer clinical outcomes: depressed patients are 3.5 x as likely to die after suffering from myocardial infarction. Despite this, depression screening is not performed widely pre operatively. To see if there is a basis to recommend routine pre operative depression screening in hip and knee arthroplasty patients, we asked all patients attending Joint School to complete a Hospital Anxiety and Depression Scale (HADS). This is a well-validated tool for assessing the presence and degree (either mild, moderate or severe if present) of anxiety and depression, using fourteen questions, and providing a score out of 21 for each. We then correlated these results to pre operative Oxford Knee and Oxford Hip Scores to see if there was any relationship between the extent of impact of disease and any mood disorder present. 190 patients completed the questionnaire pre operatively. Of those, 82 (43%) scored as anxious. 73 (38%) scored as depressed. 47 (25%) scored as both. Overall 107 (56%) were either anxious, depressed or both. The median anxiety score was 7, with 44 (54%) scoring 8–10 (mild), 35 (43%) 11–15 (moderate) and 3 (4%) 16+ (severe). The median depression score was 6, with 53 (73%) scoring 8–10 (mild), 19 (26%) 11–15 (moderate) and 1 (1%) 16+ (severe). In order to look for an association between the severity of depression or anxiety and Oxford Scores, we grouped the Oxford Scores according to the patient's score on the HADS, and performed analysis of variance (ANOVA) to look for a significant difference between the Oxford Scores in the groups. There was no significant link between increase in Oxford Score and anxiety score (p=0.173314) but there was between Oxford Score and depression score (p=0.001377). There was equally no correlation between scores in patients classified simply as anxious or not anxious (p=0.14918) but a significant difference in Oxford Score was present between patients designated as depressed or not depressed (p=0.000297). We thus conclude depression and anxiety are very common amongst pre operative arthroplasty patients and thus assessment for this should be considered routinely preoperatively. In addition, there is a link between severity of osteoarthritis and severity of depression with increasing depression score associated with increasing Oxford Score. This makes further work to assess the reasons for this link imperative: does increasing severity of osteoarthritis result in increasing severity of depression, or does depression cause patients to feel the effects of their disease more keenly, and thus score higher on Oxford Scores? If this is the case, would patients treated for depression find the effect of their joint problems severe enough to warrant undertaking arthroplasty surgery?

Introduction and Aims: Mobile bearings have been introduced in total knee arthroplasty (TKA) as a means to improve kinematics and reduce wear. Another theoretical advantage may be a reduction of the torsional and shear stresses at the baseplate – bone interface, and thereby improving the fixation of the tibial component. The aim of this study was to analyse and compare the fixation of tibial components with fixed or mobile bearings in a prospective randomised study using RSA. Method: Fifty-two consecutive patients (31 women, 21 men, mean age 72) with knee osteoarthrosis underwent primary cemented total knee arthroplasty. Included were patients with arthrosis stage III–V and age over 62. Patients were randomised at operation by opening of sealed envelopes to either Mobile Bearing (MB) or Fixed Bearing (FB). The FB knees received a NexGen TKA with titanium tibial baseplate, and the MB knees a NexGen mobile bearing TKA with CrCo tibial baseplate. All components were cemented using vacuum-mixed Palacos-Gentamicin bone cement. The stem of the component was not cemented. Patellar components were not used. Each tibial baseplate was equipped with five tantalum markers on the undersurface by the manufacturer. The peri- and post-operative management was in all cases identical. Radiostereometric analysis (RSA) was performed three, 12, and 24 months post-op. Clinical results were assessed with Knee Society Knee and Function Scores. Results: There were no complications. One patient (MB) died two months after operation in myocardial infarction. The Knee Society Knee and Function scores and range of knee motion improved after surgery in both groups with no differences between the groups, reaching 89 at both 12 and 24 months. The rotations of the tibial baseplates did not differ significantly between the two groups. In both groups, anterior-posterior tilting was somewhat larger than varus-valgus tilting. Maximum subsidence was 0.3 ± 0.1 mm (MB) and 0.2 ± 0.1 mm (FB), and maximum migration was 0.6 ± 0.2 mm (MB) and 0.5 ± 0.1 mm (FB) (P = 0.3 – 0.4). Conclusion: This study could not detect any positive effects on the fixation of the cemented tibial baseplate when a mobile polyethylene insert was used. It may be that in cemented fixation the theoretical advantages of lower shearing and torsional forces at the interface are not important, at least during the initial 24 months post-op

Benefits for the patients and for the Health Care System could rise from the adoption of a global clinical approach (“disease management approach”) for osteoporosis and its fracture complications vs the current “component-based approach”. Disease management is a kind of method aimed to manage (from a clinical and managerial perspective) highly prevalent and expensive diseases from the prevention to treatment and rehabilitation in order to improve patient outcome and to lower costs in general. Osteoporosis and its fracture complications in the Italian population meet the criteria of being highly prevalent and expensive. Four million women and 800,000 men in Italy suffer from osteoporosis. Furthermore, incidence and costs of hip fractures in the elderly Italian population (> 65 years old) are comparable to those of acute myocardial infarction in people aged > 45. Accordingly, we built a simulation model to evaluate potential benefits of a disease management approach. Incidence and costs (including drug-related costs) of hip fractures registered in Italy in 2001 were compared to those predictable in the hypothesis of treating all individuals who have at least one vertebral fracture with bisphosphonates. Almost 1.5 million people in Italy are supposed to have a vertebral fracture and consequently an increased risk of hip fracture. We considered a NTT value of 40 (“Number To Treat”: number of patients to treat in order to prevent one hip fracture), according to the FIT study (Fracture Intervention Trial, involving 6,500 patients). Only 6.4% of subjects with a vertebral fracture is currently receiving treatment with bisphosphonates. In this simulation, the extension of this anti-resorptive therapy to all individuals with vertebral fractures would produce a 48% reduction in the incidence of hip fractures (NTT=40) among people aged > 65 and increase global costs to an acceptable 21% rate. The number of hospitalisations for hip fractures in the elderly would be reduced from 78,350 (2001) to 40,850 (simulation); direct costs for hospitalisation and surgery would pass from 438 million (2001) to 236 million Euros (simulation); general costs for rehabilitation from 416 million (2001) to 224 million Euros (simulation); indirect costs from 171 to 93 million Euros; drug-related costs would rise from 46 million (0.29% of the national pharmaceutical expenses) to 750 million Euros (4.4% of the national expenses). This study seems to confirm the benefits (with regards to health and cost of illness) of a disease management approach for osteoporosis and its fracture complications

Performing Bilateral Knee replacements simultaneously is a controversial issue with proponents on both sides of the argument. The advantages of simultaneous arthroplasties include the administration of a single anaesthetic, reduced hospital stay and consequent reduced costs. Reuben et al (J. Arthroplasty, 1998) reported a 36% reduction in hospital costs. Patients also have a quicker return to function and Leonard et al (J Arthroplasty 2003) reported a high patient satisfaction rate of 95%. The primary disadvantages noted in previous studies include an increase in peri operative complications–both cardiac and pulmonary. An increase in mortality figures is perhaps the most serious complication recorded in some studies. Ritter etal (Clin. Orthop. 1997) reported a 30 day mortality rate of 0.99% in bilateral simultaneous TKA as compared to 0.3% in patients who underwent a staged procedure. Our study comprised a total of 202 patients who underwent bilateral simultaneous total knee replacements at a District General Hospital in Harlow. Harlow is one of the centres involved in the multi centric trials for the PFC Sigma Knee System and is perhaps the only centre in the UK where bilateral simultaneous procedures are carried out in significant numbers. There were 103 males and 99 females. 12 of the patients had Rheumatoid arthritis. 45% of the patients were in the 71–80 years age group, 26% in the 61–70 years age group. The average age across the entire group was 71.3 years. 35% of patients had a BMI of 25–30, 23% a BMI of 30–35, while less than 5% had a BMI of greater than 40. Most patients (44%) were ASA grade 2. The 3 most common co morbidities included hypertension(85%), coronary artery disease(25%) and diabetes mellitus (12%). 90% of the patients had the procedure performed under a General Anaesthetic and Epidural. Tourniquet time ranged from 55–159 minutes. (average 96 minutes). The patella was resurfaced in all patients. Post operatively the average drain collection was 1200 mls(range 7002600mls). Average pre op Hb was 13.8 g/dl, the post op average being 9.7 g/dl. 71% of patients required blood transfusion after surgery (average 2.8 units). Average hospital stay was 12.4 days (range 5–38 days). 6 patients required HDU admission. Complications: None in 60%; there were 3 deaths in the first 30 days(1.5%), 2 cases of pulmonary embolism(1%); 6 cases of Myocardial Infarction (3%). There were 14 superficial wound infections and 10 patients required wound washouts. An MUA was performed on 8 knees. 2 patients had Revision Knee replacements for infection. These figures are comparable to those in published literature. We have found Bilateral simultaneous Total Knee replacements to be a safe procedure with quick return to function

Background: Results after Total Hip Replacement (THR) including prosthetic design, surgical complications and prosthetic survival are frequently reported – however, information on the rate of complications in general is sparse. Aim and Methods: The aim was to collect information on all complications after THR within the first year after surgery. This study consisted of 500 consecutive patients (386 with primary THR operated due to degenerative osteoarthritis (OA) and 112 with primary THR due to secondary OA or revision THR). These patients were followed by structured interviews at surgery and 3 and 12 months after discharge. Surgical and cardiovascular complications were registered. No interventions related to this study were done. The patients followed the standard care of departments. Results: 500 patients were included; two withdrew their consent, leaving 498 for the follow up one year after surgery or until death. Of the 498 patients 103 (20.6%) experienced at least one complication related to the operation within the one year observation period. Among the 386 primary THR with degenerative OA the complicationrate was 17.9%. Of the 498 patients 6.6% experienced one or more symptomatic cardiovascular complications (deep vein thrombosis, pulmonary embolism (PE), myocardial infarction, and stroke, transient ischemic attack or retinal vein thrombosis). In the degenerative OA group 4.7% (95% Cl: 2.6–6.8%) had a cardiovascular event and in the secondary OA + revision group the rate was 13.4% (95% Cl: 10.2–16.6). The rate of complications directly related to the surgery (dislocation, perioperative fracture, bleeding, aseptic loosening, deep infection, peroneal palsy or superficial wound infection) was 15.4% (95% Cl: 12.3–18.6). In the degenerative OA and secondary OA/revision group the rates were: 14.2% and 19.6% respectively. Nine (1.8%) patients died, five of cardiovascular reasons (disseminated intravascular coagulation, PE followed by renal failure, PE followed by cerebral ischemia and stroke), the first three in close relation to the operation. Discussion: A complication-rate of 20.6% as found in the present study seems to be very high. There is no reason to think that these numbers are not correct. To our knowledge, only one other study has been published with data about complications in general (. Williams O., . J Arthroplasty. 17. :. 165. –171, . 2002. ). Their results are based on a mix of hospital file data, patient and general practitioner questionnaires with varying response rates – and their findings, although a bit lower in number, support the data from this study. The present study indicates, that there is a need for continuous registration of these common complications– even in the group of primary THR due to degenerative osteoarthritis, usually thought of as being the least complicated. The complication rate must be included in the information given to patients offered THR

Aims

To map literature on prognostic factors related to outcomes of revision total knee arthroplasty (rTKA), to identify extensively studied factors and to guide future research into what domains need further exploration.

Introduction: Posterior interbody fusion (PLIF) can be performed for a variety of indications and by a variety of methods. This paper presents a prospective observational study of the outcome for PLIF using an insert and rotate lordotic implant with pedicle screws for the indication of neurological compression caused by segmental deformity. Methods: Prospective data was collected preoperatively and at regular intervals during the post operative period. Self assessed outcome measures of visual analog pain score (VAS), Low Back Outcome Score (LBOS) and SF12 general health data was obtained at intervals after the surgery. This paper presents the results of a consecutive series who have a minimum of 6 months followup. All surgery was performed by the two authors. Implants used were a carbon fibre composite ramp (DePuy AcroMed), a titanium mesh lordotic cage (Medtronic Sofamor Danek) or a lordotic PEEK spacer (R90, Medtronic Sofamor Danek). Results: One hundred and twenty eight cases were performed. The mean age was 61.5 yrs(sd 15.1), 63 (49% ) were female and 65(51%) were male. Thirteen cases (10%) were workers compensation. Eighty seven (69%) had a single level fused, thirty three (26%) had 2 levels fused. Six cases had three or more levels fused. Forty cases had had one or more previous decompressive procedures at the target level. All cases had leg pain due to neurological compression associated with some form of deformity. Fifty three percent had a spondylolisthesis, 20 % had degenerative scoliosis with collapse of the disc space being the most common other deformity. The mean pre operative VAS pain score dropped from 6.95 (sd 2.0) to 3.2 (sd 2.4). (p< 0.0001 paired t test). The mean percentage VAS improvement was 49.7% (95% ci 42.4% to 57.1%). Twenty seven percent achieved greater then 80% pain improvement with 47% achieving greater than 60% pain improvement. The mean LBOS score rose from 21.8 (95% ci 19.6 to 24.0) to 37.9 (95% ci 35.1 to 40.6) (p< 0.001 paired t test). The mean percentage improvement in LBOS was 120.7% (95% ci 94.6% to 146%). Complications consisted of 3 cases of minor wound drainage that settled, a possible deep infection that settled with antibiotics. There were 4 cases of transient leg weakness that recovered and one case of postoperative extradural heamatoma requiring evacuation for partial cauda equina lesion (near full recovery). Unexplained persistence of leg pain or new leg pain was present 8 cases. Three cases resolved spontaneously , 2 cases were due to screw malposition and required revision and 3 cases required re-exploration for further foraminal decompression. Other medical problems included pulmonary embolus (1), chest infection/atelectasis (2), confusional state (2), paralytic ileus (3), Atrial fibrillation (2), myocardial infarction (1). Discussion: Posterior lumbar interbody fusion with insert an rotate implants for neural compression gives reasonable pain relief and reduction in disability with a low complication rate for the target (elderly) population

INTRODUCTION: Posterior interbody fusion (PLIF) can be performed for a variety of indications and by a variety of methods. This paper presents a prospective observational study of the outcome for PLIF using an insert and rotate lordotic implant with pedicle screws for the indication of neurological compression caused by segmental deformity. METHODS: Prospective data were collected pre-operatively and at regular intervals during the post-operative period. Self assessed outcome measures of visual analog pain score (VAS), Low Back Outcome Score (LBOS) and SF12 general health data were obtained at intervals after the surgery. This paper presents the results of a consecutive series who have a minimum of six months follow-up. All surgery was performed by the two authors. Implants used were a carbon fibre composite ramp (DePuy AcroMed), a titanium mesh lordotic cage (Medtronic Sofamor Danek) or a lordotic PEEK spacer (R90, Medtronic Sofamor Danek). RESULTS: One hundred and twenty eight cases were performed. The mean age was 61.5 years (sd 15.1), 63 (49% ) were female and 65 (51%) were male. Thirteen cases (10%) were workers compensation. Eighty seven (69%) had a single level fused, thirty three (26%) had two levels fused. Six cases had three or more levels fused. Forty cases had had one or more previous decompressive procedures at the target level. All cases had leg pain due to neurological compression associated with some form of deformity. Fifty three percent had a spondylolisthesis, 20% had degenerative scoliosis with collapse of the disc space being the most common other deformity. The mean pre-operative VAS pain score dropped from 6.95 (sd 2.0) to 3.2 (sd 2.4). (p< 0.0001 paired t test). The mean percentage VAS improvement was 49.7% (95% ci 42.4% to 57.1%). Twenty seven percent achieved greater than 80% pain improvement with 47% achieving greater than 60% pain improvement. The mean LBOS score rose from 21.8 (95% ci 19.6 to 24.0) to 37.9 (95% ci 35.1 to 40.6) (p< 0.001 paired t test). The mean percentage improvement in LBOS was 120.7% (95% ci 94.6% to 146%). Complications consisted of three cases of minor wound drainage that settled, a possible deep infection that settled with antibiotics. There were four cases of transient leg weakness that recovered and one case of post-operative extradural haematoma requiring evacuation for partial cauda equina lesion (near full recovery). Unexplained persistence of leg pain or new leg pain was present in eight cases. Three cases resolved spontaneously, two cases were due to screw malposition and required revision and three cases required re-exploration for further foraminal decompression. Other medical problems included pulmonary embolus (1), chest infection/atelectasis (2), confusional state (2), paralytic ileus (3), atrial fibrillation (2), myocardial infarction (1). DISCUSSION: Posterior lumbar interbody fusion with insert and rotate implants for neural compression gives reasonable pain relief and reduction in disability with a low complication rate for the target (elderly) population

In a high-risk technically advanced speciality like spine surgery, detailed information about all aspects of possible complications could be frightening for the patients, and thereby increase anxiety and distress. Therefore, aim of this study was to. Analyze written evidence of the consenting procedure pertaining to (a) nature of operation (b) benefits intended as a result of the operation (c) risks specific to the particular type of operation (c) general risks of spine surgery and anaestheia. Patients’ experiences of information regarding the risk of such complications and how the information affects the patients. Methods: 70 adult elective, consecutive patients who had been listed for Lumbar discectomy /decompression surgery were chosen. The patients were presented with questionnaire of broad-based and open-ended questions designed to elicit theirs views in each of the following areas: expectation, knowledge of risks and alternatives, and personal attitude to information and satisfaction. The study had a non-randomized design and patients divided into TWO groups Group A and group B. The patients in the group A received standard information and were consented in a routine way without being given written proforma with all complications. The patients in the group B were given the same information as patients in the control group, with written information about common and rare complications. Patients in both groups were assessed on an ‘impact of events scale’ and hospital anxiety and depression scale immediately before ad after the consent process and again after surgery when they were discharged from the hospital. For comparison of the proportion of Yes and No answers in 2 groups, Fisher’s exact test was used, and for comparison of more than 2 groups, the Chi-square test was used. For graded answers and other ordinal scales, the Mann–Whitney U-test was used for comparison of 2 groups and the Kruskal–Wallis test for comparison of more than 2 groups. Spearman’s test was used when assessing the correlation between 2 variables measured on an ordinal scale. Results: Many patients (71%) agreed that the consent form made clear what was going to happen to them, and 77%) reported that it made them aware of the risks of the operation they were to undergo. Over a third (36%) saw it as a safeguard against mixups in the operating theatre. Few patients’ decision to accept surgery appeared to depend on risk information; 8% of patients said that they might have changed their decision, had they been advised of the risks of permanent stroke and myocardial infarction. However, 92% were clear that their decision to accept treatment would not have altered. The women in the group B had symptoms of definite anxiety to a significantly higher degree than the men before the operation. Post-operatively, patients receiving extended information were significantly more satisfied with both the written and oral information about common and rare complications than patients in the control group There were no statistically significant differences between the groups for anxiety or depression, as measured by the HADS, either before or after the operation between Group A and B. Provision of extended information describing most of the possible complications did not have any negative effects on the patients. The patients receiving the extended information were more satisfied and experienced to a higher degree that they could discuss alternative treatment methods with the surgeon. Discussion: Provision of extended information describing most of the possible complications did not have any negative effects on the patients. “Ignorance is bliss” may prove to be an excellent preoperative strategy for patients when outcome is good but detrimental to long term adjustment where significant postoperative complications arise. This raises the possibility that a separate consent could be used where these risks are pre-printed and explained in vocabulary easily understood by patients. The added advantages of this form would be less confusion for the patient and there would be written evidence that patients had understood each of the major risks involved with the proposed procedure. This proposed consent form would also reduce the chance that important risks and complications are omitted when consent is being taken, as well as tackling the issue of variability of experience or lack of knowledge by the person obtaining consent

Aims

Periprosthetic joint infection (PJI) in total hip arthroplasty in the elderly may occur but has been subject to limited investigation. This study analyzed infection characteristics, surgical outcomes, and perioperative complications of octogenarians undergoing treatment for PJI in a single university-based institution.

Introduction: Uncemented total hip arthroplasty has evolved significantly over the past two decades. During this period many implants with different shapes, designs and coatings have developed and are being used with variable results. We present a series of 100 uncemented hip arthroplasties using the Duraloc 100 series cup and Corail stems which have been in use at Merlin Park for the past 5 years and 1 year respectively. The CORAIL stem first introduced in 1986 has a triplanar wedge design for optimal metaphyseal fixation. The prosthesis is pointed in its distal part to allow centering in the medullary canal without cortical locking. The titanium stem is fully coated with a 150 micron thick layer of hydroyapatite. According to the Norwegian arthroplasty register the stem has 99.5% survival at 4.5 years (Havelin L1, Espheaug B, Vollset SE, Engesaeter LB). The Duraloc 100 series acetabular cups are hemispherical, porous-coated implants that are press fitted to a cavity reamed 2mm smaller than the cup diameter. Material and methods: Between January 2002 and September 2003 we carried out 100 uncemented THRs in 65 males and 35 female patients. Patients were deemed fit for uncemented hip replacement if they had good bone stock and had no co-morbid condition which might compromise bone quality. Preoperative work up was carried out to exclude any generalised diseases that might compromise bone quality, including bone density measurements where appropriate. Baseline WOMAC scores and Harris hip scores were performed pre-operatively and at latest follow up. Operative details were recorded along with post-operative complications. Patients were followed up clinically and radiologically for a period of 6 to 26 months. Results: There were 65 male patients and 35 female patients. Average age in men was 62.5 years (range 40 to 85 years) and in women was 65 years (range 48 to 86 years). Four patients had rheumatoid arthritis, the rest had osteoarthritis. The average post-op hospital stay was 12 days. The mean WOMAC score increased from 45 pre-op to 87 at the latest follow up. The average Harris hip score also increased from 52 pre-op to 92 at latest follow up. All procedures were either performed or directly supervised by the senior authors. Operations were performed through an antero-lateral approach, the femur was prepared first and a trial reamer was left in the femoral canal to minimise blood loss while the acetabulum was reamed. The average duration of surgery was 65 minutes (range 45 to 100 mins) and average intra-operative blood loss was 300mls (range 125 to 750mls). Intra-operative complications included 2 proximal femur stable split fractures, they were identified on table and fixed with circlage cables. Patients were allowed to mobilise partial weight bearing as tolerated. Complications included 4 deep venous thromboses, three superficial wound infections, one respiratory tract infection and one myocardial infarction. At the latest follow up there are no dislocations, no deep infections and no loosening of the cup or the stem. Discussion: When considering new implants and techniques in arthroplasty long term outcome of studies are necessary before any firm conclusions can be drawn regarding ultimate efficacy. This study however confirms that uncemented THRs using Duraloc cups and Corail stems is safe, involves minimal blood loss and gives good short term results. As there is no cement used, the duration of surgery is at least 15 to 20 mins less than an average cemented THR, which may be important when access to theatre is limited. The procedure is easy to learn and has well designed instrumentation. While there is no substitute for long term studies we feel that these early results are encouraging and justify continued work with the procedure in the context of a well designed prospective randomised trial comparing cemented and uncemented femoral components

Aims

The primary aim was to assess whether preoperative health-related quality of life (HRQoL) was associated with postoperative mortality following total hip arthroplasty (THA) and knee arthroplasty (KA). Secondary aims were to assess whether patient demographics/comorbidities and/or joint-specific function were associated with postoperative mortality.

Aims

Glucose-insulin-potassium (GIK) is protective following cardiac myocyte ischaemia-reperfusion (IR) injury, however the role of GIK in protecting skeletal muscle from IR injury has not been evaluated. Given the similar mechanisms by which cardiac and skeletal muscle sustain an IR injury, we hypothesized that GIK would similarly protect skeletal muscle viability.

Aims

Periprosthetic joint infections (PJIs) and fracture-related infections (FRIs) are associated with a significant risk of adverse events. However, there is a paucity of data on cardiac complications following revision surgery for PJI and FRI and how they impact overall mortality. Therefore, this study aimed to investigate the risk of perioperative myocardial injury (PMI) and mortality in this patient cohort.