Aims. The aim of this study was to investigate mortality and risk of intraoperative medical complications depending on delay to hip fracture surgery by using data from the Norwegian Hip Fracture Register (NHFR) and the Norwegian Patient Registry (NPR). Patients and Methods. A total of 83 727 hip fractures were reported to the NHFR between 2008 and 2017. Pathological fractures, unspecified type of fractures or treatment, patients less than 50 years of age, unknown delay to surgery, and delays to surgery of greater than four days were excluded. We studied total delay (fracture to surgery, n = 38 754) and hospital delay (admission to surgery, n = 73 557). Cox regression analyses were performed to calculate relative risks (RRs) adjusted for sex, age, American Society of Anesthesiologists (ASA) classification, type of surgery, and type of fracture. Odds ratio (OR) was calculated for intraoperative medical complications. We compared delays of 12 hours or less, 13 to 24 hours, 25 to 36 hours, 37 to 48 hours, and more than 48 hours. Results. Mortality remained unchanged when total delay was less than 48 hours. Total delay exceeding 48 hours was associated with increased three-day mortality (RR 1.69, 95% confidence interval (CI) 1.23 to 2.34; p = 0.001) and one-year mortality (RR 1.06, 95% CI 1.04 to 1.22; p = 0.003). More intraoperative medical complications were reported when hospital delay exceeded 24 hours. Conclusion. Hospitals should operate on patients within 48 hours after fracture to reduce mortality and intraoperative complications. Cite this article: Bone Joint J 2019;101-B:1129–1137

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

Aims. The present study aimed to investigate whether patients with inflammatory bowel disease (IBD) undergoing joint arthroplasty have a higher incidence of adverse outcomes than those without IBD. Methods. A comprehensive literature search was conducted to identify eligible studies reporting postoperative outcomes in IBD patients undergoing joint arthroplasty. The primary outcomes included postoperative complications, while the secondary outcomes included unplanned readmission, length of stay (LOS), joint reoperation/implant revision, and cost of care. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using a random-effects model when heterogeneity was substantial. Results. Eight retrospective studies involving 29,738 patients with IBD were included. Compared with non-IBD controls, patients with IBD were significantly more likely to have overall complications (OR 2.11 (95% CI 1.67 to 2.66), p < 0.001), medical complications (OR 2.15 (95% CI 1.73 to 2.68), p < 0.001), surgical complications (OR 1.43 (95% CI 1.21 to 1.70), p < 0.001), and 90-day readmissions (OR 1.42 (95% CI 1.23 to 1.65), p < 0.001). The presence of IBD was positively associated with the development of venous thromboembolism (OR 1.60 (95% CI 1.30 to 1.97), p < 0.001) and postoperative infection (OR 1.95 (95% CI 1.51 to 2.51), p < 0.001). In addition, patients with IBD tended to experience longer LOS and higher costs of care. Conclusion. The findings suggest that IBD is associated with an increased risk of postoperative complications and readmission after joint arthroplasty, resulting in longer hospital stay and greater financial burden. Surgeons should inform their patients of the possibility of adverse outcomes prior to surgery and make appropriate risk adjustments to minimize potential complications. Cite this article: Bone Joint Res 2023;12(6):362–371

Aims. The aim of this study was to characterize the influence of social deprivation on the rate of complications, readmissions, and revisions following primary total shoulder arthroplasty (TSA), using the Social Deprivation Index (SDI). The SDI is a composite measurement, in percentages, of seven demographic characteristics: living in poverty, with < 12 years of education, single-parent households, living in rented or overcrowded housing, households without a car, and unemployed adults aged < 65 years. Methods. Patients aged ≥ 40 years, who underwent primary TSA between 2011 and 2017, were identified using International Classification of Diseases (ICD)-9 Clinical Modification and ICD-10 procedure codes for TSA in the New York Statewide Planning and Research Cooperative System database. Readmission, reoperation, and other complications were analyzed using multivariable Cox proportional hazards regression controlling for SDI, age, ethnicity, insurance status, and Charlson Comorbidity Index. Results. A total of 17,698 patients with a mean age of 69 years (SD 9.6), of whom 57.7% were female, underwent TSA during this time and 4,020 (22.7%) had at least one complication. A total of 8,113 patients (45.8%) had at least one comorbidity, and the median SDI in those who developed complications 12 months postoperatively was significantly greater than in those without a complication (33 vs 38; p < 0.001). Patients from areas with higher deprivation had increased one-, three-, and 12-month rates of readmission, dislocation, humeral fracture, urinary tract infection, deep vein thrombosis, and wound complications, as well as a higher three-month rate of pulmonary embolism (all p < 0.05). Conclusion. Beyond medical complications, we found that patients with increased social deprivation had higher rates of humeral fracture and dislocation following primary TSA. The large sample size of this study, and the outcomes that were measured, add to the literature greatly in comparison with other large database studies involving TSA. These findings allow orthopaedic surgeons practising in under-served or low-volume areas to identify patients who may be at greater risk of developing complications. Cite this article: Bone Joint J 2024;106-B(2):174–181

Aims. With resumption of elective spine surgery services in the UK following the first wave of the COVID-19 pandemic, we conducted a multicentre British Association of Spine Surgeons (BASS) collaborative study to examine the complications and deaths due to COVID-19 at the recovery phase of the pandemic. The aim was to analyze the safety of elective spinal surgery during the pandemic. Methods. A prospective observational study was conducted from eight spinal centres for the first month of operating following restoration of elective spine surgery in each individual unit. Primary outcome measure was the 30-day postoperative COVID-19 infection rate. Secondary outcomes analyzed were the 30-day mortality rate, surgical adverse events, medical complications, and length of inpatient stay. Results. In all, 257 patients (128 males) with a median age of 54 years (2 to 88) formed the study cohort. The mean number of procedures performed from each unit was 32 (16 to 101), with 118 procedures (46%) done as category three prioritization level. The majority of patients (87%) were low-medium “risk stratification” category and the mean length of hospital stay was 5.2 days. None of the patients were diagnosed with COVID-19 infection, nor was there any mortality related to COVID-19 during the 30-day follow-up period, with 25 patients (10%) having been tested for symptoms. Overall, 32 patients (12%) developed a total of 34 complications, with the majority (19/34) being grade 1 to 2 Clavien-Dindo classification of surgical complications. No patient required postoperative care in an intensive care setting for any unexpected complication. Conclusion. This study shows that safe and effective planned spinal surgical services can be restored avoiding viral transmission, with diligent adherence to national guidelines and COVID-19-secure pathways tailored according to the resources of the individual spinal units. Cite this article: Bone Jt Open 2021;2(12):1096–1101

Aims. Nonagenarians (aged 90 to 99 years) have experienced the fastest percent decile population growth in the USA recently, with a consequent increase in the prevalence of nonagenarians living with joint arthroplasties. As such, the number of revision total hip arthroplasties (THAs) and total knee arthroplasties (TKAs) in nonagenarians is expected to increase. We aimed to determine the mortality rate, implant survivorship, and complications of nonagenarians undergoing aseptic revision THAs and revision TKAs. Methods. Our institutional total joint registry was used to identify 96 nonagenarians who underwent 97 aseptic revisions (78 hips and 19 knees) between 1997 and 2018. The most common indications were aseptic loosening and periprosthetic fracture for both revision THAs and revision TKAs. Mean age at revision was 92 years (90 to 98), mean BMI was 27 kg/m. 2. (16 to 47), and 67% (n = 65) were female. Mean time between primary and revision was 18 years (SD 9). Kaplan-Meier survival was used for patient mortality, and compared to age- and sex-matched control populations. Reoperation risk was assessed using cumulative incidence with death as a competing risk. Mean follow-up was five years. Results. Mortality rates were 9%, 18%, 26%, and 62% at 90 days, one year, two years, and five years, respectively, but similar to control populations. There were 43 surgical complications and five reoperations, resulting in a cumulative incidence of reoperation of 4% at five years. Medical complications were common, with a cumulative incidence of 65% at 90 days. Revisions for periprosthetic fractures were associated with higher mortality and higher 90-day risk of medical complications compared to revisions for aseptic loosening. Conclusion. Contemporary revision THAs and TKAs appeared to be relatively safe in selected nonagenarians managed with multidisciplinary teams. Cause of revision affected morbidity and mortality risks. While early medical and surgical complications were frequent, they seldom resulted in reoperation. Cite this article: Bone Joint J 2023;105-B(6):649–656

While obesity is associated with an increased risk of complications after total hip arthroplasty (THA) the relationship between body mass index (BMI) and the risk of early postoperative complications has not been fully characterized. This study sought to describe the relationship between BMI and the risk of early postoperative complications, including periprosthetic joint infection (PJI), composite surgical, and composite medical complications. Primary, elective THAs performed from 2016–2021 were identified using the Premier Healthcare Database (PHD). The study's primary outcome was the diagnosis of PJI within 90 days of THA. Using BMI as a continuous variable, logistic regression was used to develop restricted cubic splines (RCSs) to determine the impact of BMI on PJI risk. Bootstrap simulation was used to identify an inflection point in the final RCS model. The same technique was used to characterize the effects of BMI on composite medical and surgical complications. We found that PJI risk increased exponentially beyond a BMI cutpoint of 37.4 kg/m. 2. Relative to the cutpoint, patients with a BMI of 40 or 50 kg/m. 2. were at a 1.22- and 2.55-fold increased risk of developing PJI, respectively. Surgical complications increased at a BMI of 32 kg/m. 2. and medical complications increased at a BMI of 39 kg/m. 2. Relative to these cutpoints, patients with a BMI of 50 kg/m. 2. were at a 1.36- and 2.07-fold increased risk of developing medical and surgical complications, respectively. The results of this study indicate a non-linear relationship between patient BMI and early postoperative risk of PJI, composite medical complications, and composite surgical complications following THA. The identified cutpoints with associated odds ratios can serve as tools to help risk-stratify and counsel patients seeking primary THA

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

Aims. Although there is increasing legalization of the use of cannabis in the USA, few well-powered studies have evaluated the association between cannabis use disorder and outcomes following primary total hip arthroplasty (THA). Thus, the aim of this study was to determine whether patients who use cannabis and undergo primary THA have higher rates of in-hospital length of stay (LOS), medical complications, implant-related complications, and costs. Methods. Using an administrative database, patients with cannabis use disorder undergoing primary THA were matched to a control group in a 1:5 ratio by age, sex, and various medical comorbidities. This yielded 23,030 patients (3,842 in the study group matched with 19,188 in the control group). The variables which were studied included LOS, 90-day medical complications, two-year implant-related complications, and 90-day costs of care. Mann-Whitney U tests were used to compare LOS and costs. Multivariate logistic regression analyses were used to calculate the odds ratios (ORs) of developing complications. Results. We found that patients in the study group had a significantly longer mean LOS compared with the controls (four days vs three days; p < 0.0001).The study group also had a significantly higher incidence and odds of developing medical (23.0 vs 9.8%, OR 1.6; p < 0.0001) and implant-related complications (16 vs 7.4%, OR 1.6; p < 0.0001) and incurred significantly higher mean 90-day costs ($16,938.00 vs $16,023.00; p < 0.0001). Conclusion. With the increasing rates of cannabis use, these findings allow orthopaedic surgeons and other healthcare professionals to counsel patients with cannabis use disorder about the possible outcomes following their THA, with increased hospital stays, complications, and costs. Cite this article: Bone Joint J 2021;103-B(7 Supple B):111–115

The December 2023 Knee Roundup. 360. looks at: Obesity is associated with greater improvement in patient-reported outcomes following primary total knee arthroplasty; Does mild flexion of the femoral prosthesis in total knee arthroplasty result in better early postoperative outcomes?; Robotic or manual total knee arthroplasty: a randomized controlled trial; Patient-relevant outcomes following first revision total knee arthroplasty, by diagnosis: an analysis of implant survivorship, mortality, serious medical complications, and patient-reported outcome measures using the National Joint Registry data set; Sagittal alignment in total knee arthroplasty: are there any discrepancies between robotic-assisted and manual axis orientation?; Tourniquet use does not impact recovery trajectory in total knee arthroplasty; Impact of proximal tibial varus anatomy on survivorship after medial unicondylar knee arthroplasty; Bone cement directly to the implant in primary total knee arthroplasty?; Maintaining joint line obliquity optimizes outcomes in patients with constitutionally varus knees

The recruitment drive, investment and collaboration within Betsi Cadwaladr University Health Board (BCUHB) sites providing specialist lower limb arthroplasty and trauma service has evolved over last few years with aims to improve patient care and reduce reliance on tertiary referral centres. Through our service-evaluation project, we reviewed the results of treatment provided for periprosthetic femur fractures (PPFFs) presenting to BCUHB sites over last 4 years. We retrospectively reviewed consecutive PPFFs admitted at three BCUHB sites from January’20 to June’23 with mean follow-up of 20.8 ± 13.2 (8–49) months [n=161; Mean age: 82.2 ± 8.5 (59–101) years, Females:107]. Over the review period we noted a 23% increase in service demand for care of PPFFs. Majority were managed surgically [132/161] [38 revision arthroplasties; 94 ORIFs] at BCUHB sites and two patients were referred to tertiary centre. Average time to surgery was 3.5 days. 90% of the PPFFs were managed successfully with 10% (16/159) having orthopaedic complications needing further intervention. 6.3 (10/159) had medical complications and did not need orthopaedic re-intervention. In our series, 12-month re-operation rate was 6.1% (8/132) and 1-month, 3-month and 1-year mortality rate was 6.3%, 11.3% and 21.4% respectively. These results are comparable to the published results of PPFF management at tertiary centres. Potential cost savings compared to transfer to tertiary centre for PPFF management was £2.31 million. Thus, it is possible to successfully provide adequate care for PPFFs at DGHs and efforts should be made to appropriately equip and adequately staff DGHs, to provide service for local PPFF care

Routine post-operative bloods following all elective arthroplasty may be unnecessary. This retrospective cohort study aims to define the proportion of post-operative tests altering clinical management. Clinical coding identified all elective hip or knee joint replacement under Hawkes Bay District Health Board contract between September 2019-December 2020 (N=373). Uni-compartmental and bilateral replacements, procedures performed for cancer, and those with insufficient data were excluded. Demographics, perioperative technique, and medical complication data was collected. Pre- and post-operative blood tests were assessed. Outcome measures included clinical intervention for abnormal post-operative sodium (Na), creatinine (Cr), haemoglobin (Hb), or potassium (K) levels. A cost-benefit analysis assessed unnecessary testing. 350 patients were Included. Median age was 71 (range 34-92), with 46.9% male. Only 26 abnormal post-operative results required intervention (7.1%). 11 interventions were for low Na, 4 for low K, and 4 for elevated Cr. Only 7 patients were transfused blood products. Older age (p=0.009) and higher ASA (p=0.02) were associated with intervention of any kind. Abnormal preoperative results significantly predicted intervention for Na (p<0.05) and Cr (p<0.05). All patients requiring treatment for K used diuretic medication. Preoperative Hb level was not associated with need for transfusion. Overall, there were 1027 unnecessary investigations resulting in $18,307 excess expenditure. Our study identified that the majority of elective arthroplasty patients do not require routine postoperative blood testing. We recommend investigations for patients with preoperative electrolyte abnormality, those taking diuretics, and patients with significant blood loss noted intra-operatively. In future, a larger, randomised controlled trial would be useful to confirm these factors

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

Aims. The aim of this study was to identify modifiable risk factors associated with mortality in patients requiring revision total hip arthroplasty (THA) for periprosthetic hip fracture. Methods. The electronic records of consecutive patients undergoing revision THA for periprosthetic hip fracture between December 2011 and October 2018 were reviewed. The data which were collected included age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, the preoperative serum level of haemoglobin, time to surgery, operating time, blood transfusion, length of hospital stay, and postoperative surgical and medical complications. Univariate and multivariate logistic regression analyses were used to determine independent modifiable factors associated with mortality at 90 days and one year postoperatively. Results. A total of 203 patients were identified. Their mean age was 78 years (44 to 100), and 108 (53%) were female. The median time to surgery was three days (interquartile range (IQR) 2 to 5). The mortality rate at one year was 13.8% (n = 28). The commonest surgical complication was dislocation (n = 22, 10.8%) and the commonest medical complication within 90 days of surgery was hospital-acquired pneumonia (n = 25, 12%). Multivariate analysis showed that the rate of mortality one year postoperatively was five-fold higher in patients who sustained a dislocation (odds ratio (OR) 5.03 (95% confidence interval (CI) 1.60 to 15.83); p = 0.006). The rate of mortality was also four-fold higher in patients who developed hospital-acquired pneumonia within 90 days postoperatively (OR 4.43 (95% CI 1.55 to 12.67); p = 0.005). There was no evidence that the time to surgery was a risk factor for death at one year. Conclusion. Dislocation and hospital-acquired pneumonia following revision THA for a periprosthetic fracture are potentially modifiable risk factors for mortality. This study suggests that surgeons should consider increasing constraint to reduce the risk of dislocation, and the early involvement of a multidisciplinary team to reduce the risk of hospital-acquired pneumonia. We found no evidence that the time to surgery affected mortality, which may allow time for medical optimization, surgical planning, and resource allocation. Cite this article: Bone Joint J 2020;102-B(5):580–585

Aims. Reverse shoulder arthroplasty (RSA) reliably improves shoulder pain and function for a variety of indications. However, the safety and efficacy of RSA in elderly patients is largely unknown. The purpose of this study was to report the mortality, morbidity, complications, reoperations, and outcomes of primary RSA in patients aged > 80 years. Patients and Methods. Between 2004 and 2013, 242 consecutive primary RSAs were performed in patients aged > 80 years (mean 83.3 years (. sd. 3.1)). Of these, 53 were lost to follow-up before two years and ten had died within two years of surgery, leaving 179 for analysis of survivorship, pain, motion, and strength at a minimum of two years or until revision surgery. All 242 patients were considered for the analysis of 90-day, one-year, and overall mortality, medical complications (90-day and overall), surgical complications, and reoperations. The indications for surgery included rotator cuff arthropathy, osteoarthritis, fracture, the sequela of trauma, avascular necrosis, and rheumatoid arthritis. A retrospective review of the medical records was performed to collect all variables. Survivorship free of revision surgery was calculated at two and five years. Results. One patient (0.4%) died within the first 90 days. A total of 45 patients (19%) were known to have died at the time of the final follow-up, with a median time to death of 67.7 months (interquartile range 40.4 to 94.7) postoperatively. Medical complications occurred in six patients (3%) and surgical complications occurred in 21/179 patients (12%). Survivorship free from revision was 98.9% at two years and 98.3% at five years; survivorship free from loosening was 99.5% at final follow-up. The presence of peripheral vascular disease correlated with a higher complication rate. Conclusion. Primary RSA was safe and effective in patients aged > 80 years, with a relatively low rate of medical and surgical complications. Thus, age alone should not be a contraindication to primary RSA in patients aged > 80 years. However, a careful evaluation of comorbidities is required in this age group when considering primary RSA. Cite this article: Bone Joint J 2019;101-B:1520–1525

Introduction. With the widespread legalization of cannabis across the United States, well-powered studies evaluating the impact of cannabis use disorder on outcomes following primary total hip arthroplasty are warranted. Therefore, the aim of this study was to determine whether cannabis use disorder has an effect on patients who undergo primary hip arthroplasty in terms of: 1) hospital lengths of stay (LOS); 2) medical complications; 3) implant-related complications; and 4) costs of care. Methods. Using an administrative database, patients who underwent primary total hip arthroplasty and had cannabis use disorder were matched to a cohort who did not in a 1:5 ratio by age, sex, and various medical comorbidities. This yielded 44,154 patients; 7,361 who had cannabis use disorder and 36,793 who did not. Variables for analysis included postoperative LOS, 90-day medical complications, 2-year implant-related complications, and 90-day costs of care. Mann-Whitney-U tests were used to compare LOS and costs. Multivariate logistic regression analyses were used to calculate the odds ratios (ORs) of developing complications. A p-value less than 0.005 was considered statistically significant. Results. The study found that patients who had cannabis use disorder had significantly longer in-hospital LOS (4 vs. 3 days, p<0.0001) compared to the matched cohort. Additionally, study patients were found to have significantly higher incidences and odds of developing medical (11.23 vs. 4.82%; OR: 1.47, p<0.0001) and implant-related complications (18.14 vs. 8.60%; OR: 1.50, p<0.0001). Moreover, patients who had cannabis use disorder incurred significantly higher 90-day episode of care costs ($24,585.96 vs. $23,725.93, p<0.0001). Conclusions. With the growing rates of cannabis use, this study can allow orthopaedists and other healthcare professionals to educate cannabis use disorder on the possible outcomes following their total hip arthroplasty. It should be appreciated that cannabis use disorder is associated with longer hospital stays, increased complication rates, and higher costs following primary THA

Abstract. Background. This study aims to estimate the risk of acquiring a medical complication or death from COVID-19 infection in patients who were admitted for orthopaedic trauma surgery during the peak and plateau of pandemic. Unlike other recently published studies, where patient-cohort includes a more morbid group and cancer surgeries, we report on a group more akin to those having routine elective orthopaedic surgery. Methods. The study included 214 patients who underwent orthopaedic trauma surgeries in the hospital between 12th March and 12th May 2020 when the COVID-19 pandemic was on the rise in the United Kingdom. Data was collected on demographic profile including comorbidities, ASA grade, COVID-19 test results, type of procedures and any readmissions, complications or mortality due to COVID-19. Results. There were 7.9% readmissions and 52.9% of it was for respiratory complications. Only one patient had positive COVID-19 test during readmission. 30-day mortality for trauma surgeries was 0% if hip fractures were excluded and 2.8% in all patients. All the mortalities were for neck of femur fracture surgeries and between ASA Grade 3 and 4 or in patients above the age of 70 years. Conclusion. This study suggests that presence of COVID-19 virus in the community and hospital did not adversely affect the outcome of orthopaedic trauma surgeries or lead to excess mortality or readmissions in patients undergoing limb trauma surgery. The findings also support resumption of elective orthopaedic surgeries with appropriate risk stratification, patient optimization and with adequate infrastructural support amidst the recovery phase of the pandemic

Over the last decade, the number of total knee arthroplasty (TKA) has risen over 125%. Numerous studies have established a relationship between obesity and complications in primary TKA. Interestingly, few studies have investigated medical and orthopaedic complications in obese patients undergoing revision TKA (RTKA). With the increasing number of RTKA and with the prevalence of obesity still on the rise, the study of obesity on complications following RTKA is indicated. We retrospectively reviewed 180 RTKA performed by a single surgeon done between August 2008 and June 2017. All patients who underwent RTKA were included, but revisions done with simultaneous extensor mechanism reconstruction and/or distal femur replacement were excluded since these procedures are technically more demanding. 154 revisions met our inclusion/exclusion criteriaes and were included in the final analysis. 81 patients were included in the non-obese group (BMI . The total number of orthopaedic complications in the obese group (46.6%) was significantly higher than in the non-obese group (27.2%) (OR=1.71) (p = 0.01). The number of infection was higher in the obese group (11%) than in the non-obese (6.2%) but this was not statistically significant (OR=1.77) (p = 0.28). Reoperation rate was also higher in the obese group (23.3%) than in the non-obese group (16%) but this did not reach statistical significance (OR=1.46) (p = 0.26) (Table 3). Medical complications were higher in the obese group (31.5% vs 19.8%) (OR=1.59) (p=0.09). According to the Dindo-Clavien classification, the obese group demonstrated a significantly higher rate of grade 3 or higher complications (p = 0.01). Obesity significantly increases the occurrence of orthopaedic complications following RTKA. Obesity also seems to increase the number of medical complications following RTKA. The obese patient should be informed prior to revision TKA that there is an increased risk of complications when compared with the non-obese patient. Further research with higher power would seem advisable to confirm this trend. For any figures or tables, please contact the authors directly

Aims. As the population ages, there is projected to be an increase in the level of demand for total knee arthroplasty (TKA) in octogenarians. We aimed to explore whether those aged ≥ 80 years achieved similar improvements in physical function to younger patients while also comparing the rates of length of stay (LOS), discharge to rehabilitation, postoperative complications, and mortality following TKA in older and younger patients. Patients and Methods. Patients from one institution who underwent primary elective TKA between 1 January 2006 and 31 December 2014 were dichotomized into those ≥ 80 years old (n = 359) and those < 80 years old (n = 2479) for comparison. Multivariable regression was used to compare the physical status component of the 12-Item Short-Form Health Survey (SF-12), LOS, discharge to rehabilitation, complications, and mortality between the two groups. Results. Both age groups demonstrated a clinically meaningful improvement in their self-reported physical health relative to their baseline with no clinically relevant difference noted between them. Being ≥ 80 years old was associated with a 0.58-day increase in LOS and older patients were more likely to be discharged to rehabilitation (odds ratio (OR) 3.06, p < 0.001). Medical complications and mortality were higher in elderly patients (OR 1.92 for complications, p < 0.001; hazard ratio 3.40 for death, p < 0.001). There was no statistically significant association between age group and experiencing a postoperative surgical or wound-related complication. Conclusion. Those aged over 80 years achieved a statistically significant lower median SF-12 physical score than the younger group, after adjusting for the preoperative score, but this difference of 4.46 was not considered to be clinically meaningful. However, clinicians should be aware that the elderly are at a higher risk of experiencing longer hospital stays, postoperative medical complications, and mortality. Cite this article: Bone Joint J 2018;100-B:1463–70

Aims. The aim of this study was to determine whether fixation, as opposed to revision arthroplasty, can be safely used to treat reducible Vancouver B type fractures in association with a cemented collarless polished tapered femoral stem (the Exeter). Methods. This retrospective cohort study assessed 152 operatively managed consecutive unilateral Vancouver B fractures involving Exeter stems; 130 were managed with open reduction and internal fixation (ORIF) and 22 with revision arthroplasty. Mean follow-up was 6.5 years (SD 2.6; 3.2 to 12.1). The primary outcome measure was revision of at least one component. Kaplan–Meier survival analysis was performed. Regression analysis was used to identify risk factors for revision following ORIF. Secondary outcomes included any reoperation, complications, blood transfusion, length of hospital stay, and mortality. Results. Fractures (B1 n = 74 (49%); B2 n = 50 (33%); and B3 n = 28 (18%)) occurred at median of 4.2 years (interquartile range (IQR) 1.2 to 9.2) after primary total hip arthroplasty (THA) (n = 138) or hemiarthroplasty (n = 14). Rates of revision and reoperation were significantly higher following revision arthroplasty compared to ORIF for B2 (p = 0.001) and B3 fractures (p = 0.050). Five-year survival was significantly better following ORIF: 92% (95% confidence interval (CI) 86.4% to 97.4%) versus 63% (95% CI 41.7% to 83.3%), p < 0.001. ORIF was associated with reduced blood transfusion requirement and reoperations, but there were no differences in medical complications, hospital stay, or mortality between surgical groups. No independent predictors of revision following ORIF were identified: where the bone-cement interface was intact, fixation of B2 or B3 fractures was not associated with an increased risk of revision. Conclusion. When the bone-cement interface was intact and the fracture was anatomically reducible, all Vancouver B fractures around Exeter stems could be managed with fixation as opposed to revision arthroplasty. Fixation was associated with reduced need for blood transfusion and lower risk of revision surgery compared with revision arthroplasty. Cite this article: Bone Joint J 2021;103-B(2):309–320

The aim of this study is to determine whether fixation, as opposed to revision arthroplasty, can be safely used to treat reducible Vancouver B type fractures in association with a cemented collarless polished tapered femoral stem (the Exeter). This is a retrospective cohort study of 152 operatively managed consecutive unilateral Vancouver B fractures involving Exeter stems. 130 were managed with open reduction and internal fixation (ORIF) and 22 with revision arthroplasty. Radiographs were assessed and classified by 3 observers. The primary outcome measure was revision of ≥1 component. Kaplan Meier survival analysis was performed. Logistic regression was used to identify risk factors for revision following ORIF. Secondary outcomes included any reoperation, complications, blood transfusion, length of hospital stay and mortality. Fractures (B1 n=74 (49%); B2 n=50 (33%); and B3 n=28 (18%)) occurred at mean 6.7±10.4 years after primary THA (n=143) or hemiarthroplasty (n=15). Mean follow up was 6.5 ±2.6 years (3.2 to 12.1). Rates of revision and reoperation were significantly higher following revision arthroplasty compared to ORIF for B2 (p=0.001) fractures and B3 fractures (p=0.05). Five-year survival was significantly better following ORIF: 92% (86.4 to 97.4 95%CI) Vs 63% (41.7 to 83.3), p<0.001. No independent predictors of revision following ORIF were identified: fixation of B2 or B3 fractures was not associated with an increased risk of revision. Dislocation was the commonest mode of failure after revision arthroplasty. ORIF was associated with reduced blood transfusion requirement and reoperations, but there were no differences in medical complications, hospital stay or mortality between surgical groups. When the bone-cement interface was intact and the fracture was anatomically reducible, Vancouver B2 fractures around Exeter stems can be treated with fixation as opposed to revision arthroplasty. Fixation of Vancouver B3 fractures can be performed in frail elderly patients without increasing revision risk

Our aim was to determine the effect of delay to surgery on the time to discharge, in-hospital death, the presence of major and minor medical complications and the incidence of pressure sores in patients with a fracture of the hip. All patients admitted to Vancouver General Hospital with this injury between 1998 and 2001 inclusive were identified from our trauma registry. A review of the case notes was performed to determine the delay in time from admission to surgery, age, gender, type of fracture and medical comorbidities. A time-to-event analysis was performed for length of stay. Additionally, a Cox proportional hazards model was used to determine the effect of delay to surgery on the length of stay while controlling for other pertinent confounding factors. Using logistical regression we determined the effect of delay to surgery on in-hospital death, medical complications and the presence of pressure sores, while controlling for confounding factors. Delay to surgery (p = 0.0255), comorbidity (p < 0.0001), age (p < 0.0001) and type of fracture (p = 0.0004) were all significant in the Cox proportional hazards model for increased time to discharge. Delay to surgery was not a significant predictor of in-hospital mortality. However, a delay of more than 24 hours was a significant predictor of a minor medical complication (odds ratio (OR) 1.53, 95% confidence interval (CI) 1.05 to 2.22), while a delay of more than 48 hours was associated with an increased risk of a major medical complication (OR 2.21, 95% CI 1.01 to 4.34), a minor medical complication (OR 2.27, 95% CI 1.38 to 3.72) and of pressure sores (OR 2.29, 95% CI 1.19 to 4.40). Patients with a fracture of the hip should have surgery early to lessen the time to acute-care hospital discharge and to minimise the risk of complications

Aims. Two-stage exchange arthroplasty is the most common definitive treatment for prosthetic joint infection (PJI) in the USA. Complications that occur during treatment are often not considered. The purpose of this study was to analyze complications in patients undergoing two-stage exchange for infected total knee arthroplasty (TKA) and determine when they occur. Methods. We analyzed all patients that underwent two-stage exchange arthroplasty for treatment of PJI of the knee from January 2010 to December 2018 at a single institution. We categorized complications as medical versus surgical. The intervals for complications were divided into: interstage; early post-reimplantation (three months); and late post-reimplantation (three months to minimum one year). Minimum follow-up was one year. In total, 134 patients underwent a first stage of a two-stage exchange. There were 69 males and 65 females with an mean age at first stage surgery of 67 years (37 to 89). Success was based on the new Musculoskeletal Infection Society (MSIS) definition of success reporting. Results. Overall, 70 (52%) patients experienced a complication during the planned two-stage treatment, 36 patients (27%) experienced a medical complication and 47 (41%) patients experienced a surgical complication. There was an 18% mortality rate (24/134) at a mean of 3.7 years (0.09 to 8.3). During the inter-stage period, 28% (37/134) of patients experienced a total of 50 complications at a median of 47 days (interquartile range (IQR) 18 to 139). Of these 50 complications, 22 were medical and 28 required surgery. During this inter-stage period, four patients died (3%) and an additional five patients (4%) failed to progress to the second stage. While 93% of patients (125/134) were reimplanted, only 56% (77/134) of the patients were successfully treated without antibiotic suppression (36%, 28/77) or with antibiotic suppression (19%, 15/77) at one year. Conclusion. Reported rates of success of two stage exchanges for PJI have not traditionally considered complications in the definition of success. In our series, significant numbers of patients experienced complications, more often after reimplantation, highlighting the morbidity of this method of treatment. Cite this article: Bone Joint J 2020;102-B(6 Supple A):145–150

Introduction. Hip arthroplasty is one of the most common procedures performed every year however complications do occur. Prior studies have examined the impact of insurance status on complications after TJA in small or focused cohorts. The purpose of our study was to utilize a large all-payer inpatient healthcare database to evaluate the effect of patient insurance status on complications following hip arthroplasty. Methods. Data was obtained from the Nationwide Inpatient Sample between 2004 and 2011. Analysis included patients undergoing hip arthroplasty procedures determined by ICD-9 procedure codes. Patient demographics and comorbidities were analyzed and stratified by insurance type. The primary outcome was medical complications, surgical complications and mortality during the same hospitalization. A secondary analysis was performed using a matched cohort comparing patients with Medicare vs private insurance using the coarsened exact matching algorithm. Pearson's chi-squared test and multivariate regression were performed. Results. Overall, 1,011,184 (64.8% Medicare, 29.3% private insurance, 3.7% Medicaid or uninsured, 2.0% Other) patients fulfilled criteria for inclusion into the study. Most were primary total hip arthroplasties (64.2%) and primary hip hemiarthroplasty (29.8%), with 6% revision hip arthroplasties. Multivariate regression analysis showed that patients with private insurance had fewer complications (OR 0.8, p=<0.001) and those with Medicaid or no insurance had more medical complications (OR 1.06, p=0.005) compared to Medicare patients. Similar trends were found for surgical complications and mortality. The matched cohort showed Medicare and private insurance patients had similar complication rates. The most common complication was postoperative anemia, occurring in 22.6% of Medicare patients and 21.1% of patients with private insurance (RR=1.06, p<0.001). Discussion and. Conclusion. This data reveals that patients with Medicare, Medicaid or no insurance have higher risk of medical complications, surgical complications and mortality following hip arthroplasty. Using a matched cohort to directly compare Medicare and private insurance patients, the risk of postoperative complications are similar and generally low with the notable exception of the most common complication, postoperative anemia, which occurs more frequently in patients with Medicare

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

Acute pain is one of the most common symptoms shared among patients who have suffered from an orthopedic trauma such as an isolated upper limb fracture (IULF). Development of interventions with limited side effects aiming to prevent the installation of chronic pain is critical as persistent pain is associated with an increased risk of opioid dependence, medical complications, staggering financial burdens and diminished quality of life. Theta burst stimulation (TBS), a non-invasive magnetic brain stimulation technique with minimal side effects, has shown promising results in patients experiencing various types of chronic pain conditions as it precisely targets brain regions involved in pain processing. Surprisingly, its impact on acute pain has never been investigated. This study aims to assess longitudinal effects of a 10-day continuous TBS (cTBS) protocol applied in the acute phase of an IULF on key functional outcomes. Patients with an IULF aged between 18 to 60 years old were recruited within 7 days post-accident at a Level I Trauma Center. Exclusion criteria included a history of brain injury, neurological disorders, musculoskeletal complications, and open fractures. In order to assess longitudinal changes, questionnaires measuring intensity and characteristics of pain (Numerical Rating Scale, NRS; McGill Pain Questionnaire, MPQ) as well as functional disability (DASH) were completed by all patients at three time points, namely prior to the start of the TBS program as well as 72 hours and 3 months post-intervention. Patients were randomly attributed to the active TBS protocol (active group) or to the placebo protocol (sham group). The stimulation site for each participant corresponded to the contralateral motor cortex of the injured arm. Fifty patients were recruited (female: 24; age: 40.38 years old), of which 25 were in the active group and 25 were in the sham group. Both groups were equivalent based on age, sex, type of injury, and surgical procedures (p>0.05). The intervention protocol was introduced on average 6.18 days post-accident. In comparison to the sham group, the active group showed a significant decrease in pain intensity (NRS) at 72h (F=6.02; p=0.02) and 3-month (F=6.37; p=0.02) post-intervention. No group difference was found early-on (72h post) in regard to pain characteristics (MPQ; F=3.90; p=0.06) and functional disabilities (DASH; F=0.48; p= 0.49). At three-month post-intervention, the active group showed statistically significant improvement on the MPQ (F=5.02; p=0.04) and the DASH (F=5.88; p=0.02) compared to the placebo group. No complications related to the treatment were reported. Results from this study show that patients who underwent active cTBS reported less pain and better functional states shortly after the end of the TBS protocol compared to sham patients and treatment effects were maintained at three months post-intervention. Given that acute pain intensity is an excellent predictor of chronic pain development, this safe technique available in numerous centers in Canada may help prevent chronic pain development when administered during the acute post-injury phase. Future studies should continue to investigate mechanisms involved to optimize this technique among the orthopedic trauma population and to reduce opioid consumption

Introduction. Prosthetic joint infection (PJI) is an devastating complication after total hip arthroplasty (THA). The common treatment in the US is a two-stage exchange which can be associated with significant morbidity and mortality. The purpose of this study was to analyze complications in the treatment course of patients undergoing two-stage exchange for PJI THA and determine when they occur. Methods. We analyzed all patients that underwent two-stage exchange arthroplasty for treatment of PJI after THA from January 2005 – December 2017 at a single institution. Complications were categorized as medical or surgical, divided into three intervals: (1) inter-stage, (2) early post-reimplantation (<90 days) and (3) late post-reimplantation (> 90 days). Minimum follow up was one year. Success was based on the Musculoskeletal Infection Society (MSIS) definition. Results. 185 hips underwent first stage of planned two stage exchange. The median age was 65 (IQR 18). There were 93 males and 92 females. 73 patients had a complication during treatment. 13.5% (25/185) of patients experienced a medical complication and 28.1% (52/185) a surgical complication. There was a 14.1% (26/185) mortality at a median of 2.5 years (IQR 4.9). 51(29%) had complications during the interstage period, most common being recurrence of infection requiring a spacer exchange (48.6%). 2 patients died and 2 patients failed to progress to the second stage. 22(12%) complications following re-implantation, most commonly persistence /recurrence of infection (31%). 183/185 patients that initiated a two stage exchange were re-implanted, only 65% (120/185) were successfully treated with or without antibiotic suppression at one-year without additional surgery. Conclusions. While 2 stage exchanges for PJI in THA have been reported as successful, there are few reports of the complications during the process. In our series, significant numbers of patients experienced complications, often during the interstage period, highlighting the morbidity of this method of treatment

An increasing number of patients with hepatitis B virus (HBV) infection are progressing in age and are undergoing total joint arthroplasty (TJA) surgery in China. Less attention is provided to the special populations. This study aimed to evaluate the effect of HBV on TJAs. We retrospectively reviewed all patients who met the inclusion of undergoing elective primary hip and knee arthroplasties from 2013– 2016. Non-hepatitis B cohort was built to match the case cohort to identify whether HBV infection was a risk factor associated with postoperative complications. A total number of 197 patients who underwent primary TJAs were involved in the study, including 49 patients with hepatitis B and 147 non-hepatitis B subjects. Among all the patients with TJAs, we obtained a 5.5% HBV infection rate for the first time. Compared with patients without hepatitis B, patients with hepatitis B had higher rates (P < 0.01) of total complications (10.2% compared to 4.7%), surgery-related complications (6.1% compared to 3.4%), and general medical complications (4.1% compared to 1.3%) than the non-hepatitis B group. Patients with hepatitis B infection had a 21% increased risk (95% CI, 0.97–1.46; p < 0.01) of total complication compared with non-hepatitis B group. Similar results were obtained for medical and surgical complications. HBV infection had a 31% increased risk (95% CI, 1.02–1.62; p < 0.01) for medical complication and 18% risk (95% CI, 0.95–1.42; p < 0.01) for surgical complication. In the subgroup analysis, no difference was found between the surgical methods and sex, whereas a significant difference of CRP change level (P < 0.01) was found between HBV group and the matched group in the clinical laboratory values. This is the first study of patients with hepatitis B undergoing primary THA or TKA and demonstrates an increased risk of multiple perioperative complications in a Chinese population. In consideration of the large population of HBV infection in China, more attention should be provided to patients with HBV infection who need to undergo TJAs

Although wait-times for hip fracture surgery have been linked to mortality and are being used as quality-of-care indicators worldwide, controversy exists about the duration of the wait that leads to complications. Our objective was to use new population-based wait-time data to emprically derive an optimal time window in which to conduct hip fracture surgery before the risk of complications increases. We used health administrative data from Ontario, Canada to identify hip fracture patients between 2009 and 2014. The main exposure was the time from hospital arrival to surgery (in hours). The primary outcome was mortality within 30 days. Secondary outcomes included a composite of mortality or other medical complications (MI, DVT, PE, and pneumonia) also within 30 days. Risk-adjusted cubic splines modeled the probability of each complication according to wait-time. The inflection point (in hours) when complications began to increase was used to define ‘early’ and ‘delayed’ surgery. To evaluate the robustness of this definition, outcomes amongst propensity-score matched early and delayed patients were compared using percent absolute risk differences (% ARDs, with 95% confidence intervals [CIs]). There were 42,230 patients who met entry criteria. Their mean age was 80.1 (±10.7) and the majority were female (70.5%). The risk of complications modeled by cubic splines consistently increased when wait-times were greater than 24 hours, irrespective of the complication considered. Compared to 13,731 propensity-score matched patients who received surgery earlier, 13,731 patients receiving surgery after 24 hours had a significantly higher risk of 30-day mortality (N=898 versus N=790, % ARD 0.79 [95% CI 0.23 to 1.35], p = .006) and the composite outcome (N=1,680 versus N=1,383, % ARD 2.16 [95% CI 1.43 to 2.89], p < .001). Overall, there were 14,174 patients (33.6%) who received surgery within 24 hours and 28,056 patients (66.4%) who received surgery after 24 hours. Increased wait-time was associated with a greater risk for 30-day mortality and other complications. The finding that a wait-time of 24 hours represents a threshold defining higher risk may inform existing hip fracture guidelines. Since two-thirds of patients did not receive surgery within this timeframe, performance improvement efforts that reduce wait-times are warranted

Background. Previous surgery is known to increase the risk of complications during spine surgery, but few studies have quantified the dose-response effect using multivariate models to account for confounders. We quantified the effect of the number of prior spine surgeries on perioperative complications in patients undergoing surgery for lumbar degenerative disorders. Methods. We included data from 4′940 patients documented in Eurospine's Spine Tango Registry from 2004 to 2015. Medical history and surgical details were documented on the Tango Surgery form, as were surgical and general medical complications arising between admission and discharge. Multiple logistic regression models were built to investigate the relationship between the number of any previous surgeries and the presence of a perioperative complication, controlling for other potential confounders (age, sex, smoking, BMI, comorbidity, number of vertebral levels affected). Results. There were 9.4% surgical complications (most commonly dural tear, neurological sequelae, haematoma, infection) and 6.5 % general complications (most commonly cardiovascular, urinary, pulmonary, liver/GI). In the multivariable models, previous surgery significantly increased the odds of having a surgical complication (OR 1.148, 95%CI 1.051–1.253; p=0.002) and a medical complication (OR 1.185, 95%CI 1.074–1.307; p=0.001) i.e., for each previous surgery, the odds of a complication increased by 15% and 19%, respectively. Conclusion. We demonstrated a significant dose-response effect of previous surgery on the risk of incurring a complication during subsequent spine surgery. The results can be used by the surgeon when assessing the risk/benefit ratio of further surgery, for informing and consenting the patient. No conflicts of interest. No funding obtained

Aim: We audited medical complications after revision hip arthroplasty, in elderly and young patients and correlated its occurrence to the preoperative medical status. Methods: 104 revision hip replacements in 100 patients (mean age 71.5 years) were followed up for a mean of 33.9 months. (9–67). 49 were above 75 years of age. The American Society of Anaesthetists grading system was used to assess preoperative medical fitness. 50% patients were in ASA grade III. Medical complications in the first 3 postoperative months were classified into major, moderate and minor (Phillips). There were pre-existing cardiac problems in 57, COPD in 13, vascular disease in 7, cerebro vascular disease in 7, previous DVT in 6 and renal/endocrine problems in 16. Results: Overall medical complication rate was 35% (7% major, 14% moderate and 14% minor). The rate in elderly patients was 21%. There was 1 postoperative death due to cardiac reasons at 2 months. There were cardiac complications in 23%, anaemia in 17%, respiratory problems in 10%, hematemesis in 7%, renal in 7%, circulatory in 7%, deep vein thrombosis in 5%, pulmonary thromboembolism in 5%. Mean hospital stay was 17.8 days. 83 patients had no pain, 88 were independent, and 7 had poor mobility. 85% were satisfied with the operation. The major medical complications were not significantly higher in elderly than in younger patients. Conclusion ASA grade correlated positively with frequency and severity of medical complications (Fisher exact test p < 0.001). The occurrence was independent of the age of the patient (p=0.106). Revision hip arthroplasty was well-tolerated in elderly patients and age alone is not a contra-indication. This compared favourably with other reported series. Good anaesthetic and medical support is vital

Given the high prevalence of psychiatric illness in the total joint arthroplasty (TJA) population, relatively little is known about how these two conditions affect each other. Therefore, the purpose of this study is to evaluate the role of major psychiatric illness on patient specific outcomes after TJA. We hypothesize that patients with major psychiatric illnesses will report inferior outcomes and have more complications after TJA compared to those without any psychiatric illness. We matched and compared two cohorts of patients undergoing TJA from a prospectively collected database registry, which included those with and without a major psychiatric disorder. Major psychiatric disorder was identified in the registry database by determining if patients had been formally diagnosed with any of the following conditions: bipolar disorder, major personality disorder, chronic mental health diagnoses, depression, or schizophrenia. Primary outcomes of interest included patient specific outcomes measured using the WOMAC or EQ5D. Secondary outcomes included complications, infections, hospital length of stay, 30-day readmission rates and final discharge destination. In total we included 1828 TJAs (1000 THAs, 828 TKAs). In terms of the primary outcome, both the THA experimental group (37.80 ± 17.91 vs. 40.74 ± 19.3, p=0.023) and TKA experimental group (43.38 ± 18.41 vs 45.45 ± 20.07, p=0.050) had significantly lower preoperative WOMAC scores compared to their respective control groups. At the 3-month period both the THA experimental group (76.74 ± 16.94 vs. 79.16 ± 16.19, p=0.036) and TKA experimental group (71.09 ± 18.64 vs. 75.92 ± 16.22, p=0) again had significantly lower 3-month postoperative WOMAC score. Clinical outcomes at the 1-year mark were similar for both groups in terms of WOMAC and EQ5D. Patients with psychiatric illness were more likely to have increased LOS and non-routine discharge from hospital. In the THA subset, the experimental group had an increased LOS by 1.43 days (p=0.0028), in the TKA subset, the experimental group had an increased LOS by 0.77 days (p= 0.050). In terms of non-routine discharge, the THA experimental group was discharged home 86.9% of the time compared to the control group at 91.8% (p=0.024). In the TKA subset, the experimental group was discharged home 87.6% of the time compared to the control group at 92% (p=0.022). There were no other differences between the two subsets in regards to transfusions, 30-day readmissions, infections, mechanical adverse events, and medical complications. In conclusion, our results demonstrate that psychiatric illness can result in worse outcomes in the early perioperative period after TJA, although outcomes are equivalent 1 year postoperatively. Patients with psychiatric illness can be expected to gain significant improvements in outcome after surgery that are comparable to a baseline population without psychiatric illness. Nonetheless, patients with psychiatric illness are at increased risk of delayed discharge and non-routine discharge. As such, they may require personalized care post-operatively, and should be counseled accordingly. Based on our results, psychiatric illness should not be an impediment to proceeding with TJA

INTRODUCTION. Shoulder arthroplasty (SA) is an effective procedure for managing patients with shoulder pain secondary to degenerative joint disease or end stage arthritis that has failed conservative treatment. Insurance status has been shown to be an indicator of patient morbidity and mortality. The objective of the current study is to evaluate the effect of patient insurance status on outcomes following shoulder replacement surgery. METHODS. Data was obtained from the Nationwide Inpatient Sample between 2004 and 2011. Analysis included patients undergoing shoulder arthroplasty procedures determined by ICD-9 procedure codes. Patient demographics and comorbidities were analyzed and stratified by insurance type. The primary outcome was medical and surgical complications occurring during the same hospitalization with secondary analysis of mortality. Pearson's chi¬squared test and multivariate regression were performed. RESULTS. A data inquiry identified 103,290 patients (68,578 Medicare, 27,159 private insurance, 3,544 Medicaid/uninsured, 4,009 Other) undergoing partial, total and reverse total shoulder replacements. The total number of complications was 17,810 (17.24%), and the top three complications included acute cardiac events (8,165), urinary tract infections (3,154), and pneumonia (1,635). The highest complication rate was observed in the Medicare population (20.3%), followed by the Medicaid/uninsured (16.9%), other (11.1%), and the privately-insured cohort (10.5%). Multivariate regression analysis indicated that having Medicare insurance, white race, increasing age, higher comorbidity, and urgent or emergent admissions was associated with medical complications. Black patients, increasing age and comorbities was associated with surgical complications. Overall mortality was 0.20% and was more common in total shoulder arthroplasty and surgeries done on emergent or urgent admissions. DISCUSSION. This data reveals that patients with Medicare, Medicaid or no insurance were more likely to have medical complications, most commonly cardiac complications, UTIs and pneumonia. Primary insurance payer status can be considered as an independent risk factor during preoperative risk stratification and planning

Introduction. Interferon (IFN) based treatments for chronic hepatitis C (HCV) have been the standard of care until 2014 when direct antiviral agents (DAA) were introduced. Patients with HCV have had extremely high complication rates after total hip arthroplasty (THA). It is unknown whether HCV is a modifiable risk factor for these complications prior to THA. The purpose of this study was 1) to compare perioperative complication rates between untreated and treated HCV in THA and 2) to compare these rates between patients treated with two different therapies (IFN vs. DAA). Methods. A multicenter retrospective database query was used to identify patients diagnosed with chronic hepatitis C virus who underwent total hip arthroplasty from 2006–2016. All patients (n=105) identified were included and were divided into two groups: untreated HCV (n=63) and treated (n=42); the treated group were further subdivided into those receiving IFN based therapies (n=16) or DAA therapies (n=26). Comparisons between the treated and untreated groups were made with respect to demographic data, comorbidities, preoperative viral load, MELD score, and all surgical (≤1 yr) and medical (≤90d) complications; a sub-group analysis of the treated patients was also performed. Separate independent t-tests were conducted for dependent variables that were normally distributed, and Mann-Whitney U tests were conducted for variables which were not normally distributed. Categorical variables were compared through the chi-square test of independence. The level of statistical significance was set at p<0.05. Results. Of the 105 patients, there was a greater number of HIV infected patients in the untreated group and a higher number of smokers in the treated group. Surgical complication rates were higher in the untreated group (25.4% vs. 4.8%; p<0.05) with a PJI rate of 14.3% in the untreated group. There were no differences in medical complications. A sub-group analysis of the different treatments for HCV did not reveal any differences in post-surgical complications. Discussion and Conclusion. Untreated HCV is traditionally associated with an extremely high rate of postoperative complications following THA. Treatment for HCV prior to THA appears to be associated fewer postoperative complications, primarily PJI. While further investigation is warranted, strong consideration should be given to treating patients for HCV prior to elective THA

Purpose: We aimed to determine the effect of delay to surgery in hip fracture patients, including in hospital mortality, major complications, minor complications and length of hospital stay. Method: We identified 615 eligible patients from the VGH Orthopaedic Trauma database between 1998 and 2002. A thorough chart review was performed. Age, gender, time from admission to surgery, pre-existing medical comorbidity, length of acute care hospital stay, major medical complications, minor medical complications and in hospital death were recorded and categorized. Patients were categorized into three risk groups for pre-existing comorbidity, and three groups for delay to surgery (48 hours). Chi-squared tests were performed to determine the association of delay to surgery to death, major complications, minor complications and length of stay, as a categorical variable. Multivariate logistic regression analysis was used to evaluate these associations, while adjusting for age, gender, and pre-existing medical comorbidity. Anvoa test was used to evaluate the association between length of stay, as a continuous variable, and delay to surgery. Results There were 471 female patients, and 141 male patients. We identified 52 deaths (8.5%), 72 major complications (11.7%) and 238 minor complications (38.7%). The delay to surgery was < 24 hours in 346 patients (56.3%), 24–48 hours in 216 (35.1%), and > 48 hours in 50 (8.1%). The mean length of hospital stay was 23.4 days. Chi squared test showed no statistically significant association between delay to surgery and in hospital death (p= 0.787), despite a trend to increasing death (< 24 hours 8.1%, 24–48 hours 8.3%, > 48 hours 12.2%). There was no statistically significant association between delay and minor complications. Statistically significant associations between delay to OR and length of hospital stay (p= 0.0026), and the occurrence of a major complication (p=0.0085) were found. Regression analysis of major complications revealed an odds ratio of 1.47 for the > 48 hour group compared to the < 24 hour group, with a confidence interval of 1.15–1.87. Regression analysis did not show a statistically significant odds ratio for either death or minor complications. Conclusion: There is a trend to increasing mortality and minor complications with a delay to surgery in hip fractures. A statistically significant increase in major medical complications and length of hospital stay with delay to surgery was found in our group. Regression analysis including age, gender and pre-existing medical comorbidity supported the significance of the increased risk of major medical complications with delay, adjusted for age, gender, and pre-existing medical comorbidity

Introduction. Intervertebral disc degeneration (IVDD) associated with low back pain is a major contributor to global disability. Current treatments are poorly efficient in the long-term resulting in medical complications. Therefore, minimally invasive injectable therapies are required to repopulate damaged tissues and aid regeneration. Among injectable biomaterials, self-assembling peptide hydrogels (SAPHs) represent potential candidates as 3D cell carriers. Moreover, the advent of graphene-related materials has opened the route for the fabrication of graphene-containing hydrogel nanocomposites to direct cellular fate. Here, we incorporated graphene oxide (GO) within a SAPH to develop a biocompatible and injectable hydrogel to be used as cell carrier to treat IVDD. Methods and results. Hydrogel morphology and mechanical properties have been investigated showing high mechanical properties (G'=12kPa) comparable with human native nucleus pulposus (NP) tissue (G'=10kPa), along with ease of handling and injectability in dry and body fluid conditions. Hydrogel nanocomposites resulted biocompatible for the encapsulation of bovine NP cells, showing higher viability (>80%) and metabolic activity in 3D cell culture over 7 days, compared to GO-free hydrogels. Moreover, GO has demonstrated to bind TGF-β3 biomolecules with high efficiency, suggesting the use of GO as local reservoir of growth factors within the injected hydrogel to promote extracellular matrix deposition and tissue repair. Conclusions. Our results show that incorporation of GO within the SAPH improves cell viability and metabolic activity. Furthermore, its tissue-mimicking mechanical properties and chemical tunability make it a promising candidate as injectable carrier of NP cells for the treatment of IVDD. Part of this work has been published (DOI: 10.1016/j.actbio.2019.05.004). Conflicts of interests: No conflicts of interest. Sources of funding: The authors thank the EPSRC & MRC CDT in Regenerative Medicine for its financial support (EP/L014904/1)

Introduction. Two-stage exchange arthroplasty remains the gold standard for treatment of PJI with reported success rates of 85–90%. Complications that occur during treatment are often not reported or considered in the success rate. The purpose of this study was to analyze complications in patients undergoing two-stage exchange and determine when they occur. Methods. We analyzed all patients that underwent two-stage exchange arthroplasty for treatment of chronic PJI of the knee from 2010 to 2018. We categorized complications as medical vs. surgical. The intervals for complications were divided into: interstage, early post re-implant (3 months) and late post re-implant (3 months to minimum 1 year). Minimum follow-up to evaluate complications was one year. Results. Overall, 132 patients underwent a first stage of a two-stage exchange. There were 63 males and 59 females with an average age at first stage surgery of 66.6 years (SD: 8.9). Ten patients (7.6%) did not undergo re-implantation following resection arthroplasty (8 retained spacers and 2 deaths). 122 patients underwent the planned second stage of a two-stage exchange arthroplasty of the knee. The overall success rate (re-implant without recurrence of infection) was 78%. Overall mortality was 1.6% at one year and 9% at 5 years after treatment. Fifty-six patients (46%) experienced at least one complication. 43 patients had an orthopaedic related complication that required additional surgery and 13 patients had a medical complication. 33% of the total complications occurred during the interstage period, 18% within 90 days of reimplant, and 37% greater than three months from reimplant (p=0.0287). Discussion. Reported rates of success of two stage exchanges for PJI have not traditionally considered complications in the definition of success. In our series, significant numbers of patients experienced complications, more often after reimplantation, highlighting the morbidity of this method of treatment and the need for in-depth patient counseling, careful surgical technique, and close follow up. For figures, tables, or references, please contact authors directly

Introduction. The commonest causes of revision of Unicompartmental Knee Replacement (UKR) in National Registers are loosening and pain. Cementless UKR was introduced to address loosening and was found, in small randomised studies, to have better radiographic fixation than Cemented UKR. Although non-significant these studies also suggested the clinical outcome was better with cementless. The aim of this larger study was to compare the pain and function of cementless and cemented UKR at five years. Methods. 263 Cemented and 266 Cementless UKR of identical design, implanted by four high volume surgeons for the same indications, were reviewed by independent physiotherapists at five years. Revision, re-operation, Oxford Knee Score (OKS), American Knee Society score (AKSS) and EQ-5D were assessed. Two pain specific scores were also used: Pain Detect (PD) and Intermittent and Constant Osteoarthritis Pain (ICOAP). The pain scores were normalised onto a scale of 0 to 100 with 100 being the best. The cemented cohort was mainly implanted before the cementless, although there was considerable overlap. To explore whether differences were due to progressive improvement in surgical practice with time each cohort was divided into early and late subgroups. Results. Pre-operatively there were no differences between the devices in patient demographics or scores. At 5 years there were no differences in revision rate (0.8%), re-operation rate (2.2%) or medical complication rate (4%). The Cementless had significantly (p<0.05) better OKS (43 v 41), AKSS and EQ5D. There were significantly (p=0.03) fewer cementless cases with unexplained pain (2.3% v 6%). The cementless had significantly (p<0.002), less ‘strongest’ (84 v 76) and ‘average’ (90 v 85) pain as assessed by PD and less chronic (97 v 92) and intermittent (93 v 86) pain as assessed by ICOAP. Subgroup analysis found no significant differences in outcome between the early and late subgroups within the cohorts, whereas there were significant differences in outcomes between the late subgroup of the cemented cohort and the early subgroup of the cementless cohort. Discussion and Conclusion. Almost all outcome scores were significantly better following cementless compared to cemented UKR, suggesting that the cementless is better than cemented. However, as the cemented cases were mainly implanted before the cementless, it could be the difference was due to other factors, such as surgical technique or rehabilitation, that improved with time. This is unlikely to be the case as there were no differences between the early and late subgroups within the cohorts whereas there were differences between the late subgroup of the cemented cohort and the early subgroup of the cementless cohort which were implanted at a similar time. Although the functional scores following cementless are significantly better than cemented, the differences are similar to or smaller than the minimally clinical important difference (MCID) for these scores. In contrast there is significantly less pain following the cementless and the differences tended to be greater than the MCID. This suggests that Cementless UKR is associated with appreciably less pain and slightly better function than Cemented UKR. For figures, tables, or references, please contact authors directly

The February 2023 Foot & Ankle Roundup³⁶⁰ looks at: Joint inflammatory response in ankle and pilon fractures; Tibiotalocalcaneal fusion with a custom cage; Topical application of tranexamic acid can reduce blood loss in calcaneal fractures; Risk factors for failure of total ankle arthroplasty; Pain catastrophizing: the same as pain forecasting?.

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

Aims

Total hip arthroplasty (THA) is considered the preferred treatment for displaced proximal femoral neck fractures. However, in many countries this option is economically unviable. To improve outcomes in financially disadvantaged populations, we studied the technique of concomitant valgus hip osteotomy and operative fixation (VOOF). This prospective serial study compares two treatment groups: VOOF versus operative fixation alone with cannulated compression screws (CCSs).

INTRODUCTION. The direct anterior approach (DAA) for total hip arthroplasty has become a popular technique. Proponents of the anterior approach cite advantages such as less muscle damage, lower dislocation risk, faster recovery, and more accurate implant placement for the approach. However, there is a steep, complex learning curve associated with the technique. The present study seeks to define the learning curve based on individual surgical and outcome variables for a high-volume surgeon. METHODS. 300 consecutive patients were retrospectively analyzed. Intraoperative outcomes measured include surgery time and estimated blood loss (EBL). Complications include intraoperative fracture, post-operative fracture, infection, dislocation, leg length discrepancy, loosening, and medical complications such as deep vein thrombosis (DVT) and pulmonary embolism (PE). Segmented regression models were used to elucidate the presence of a learning curve and mastery of the procedure with regard to each individual variable. RESULTS. The mean operative time was 77.1 minutes (range 40–213). Operative time improved at a rate of 6.6 minutes per case for the first 15 cases then by an average of 5 seconds per subsequent case. The mean EBL for the series was 288.6 mL. Segmented regression shows EBL decreased at a rapid rate until case 52, followed by a more gradual decline. Complications were higher in the first 7 surgeries, with a 48% decrease in the likelihood of complication with each subsequent surgery. The improvement continued through the rest of the series with a 0.5% decrease in likelihood with each surgery. DISCUSSION. Our data contributes to the current body of literature by defining the learning curve with what we consider the most pertinent outcomes. First, we show that operative efficiency can be gained quite quickly (15 cases) while the slower improvement in EBL demonstrates continued learning about the anatomy. Our data is consistent with previous published reports regarding complication improvement. The present study will provide surgeons considering DAA useful information regarding what to expect during their learning curve. Furthermore, the data can be useful for surgeons charged with teaching the technique to critically evaluate what learning curve variables can be improved to hasten the learning curve

Aims

The purpose of this study was to compare reoperation and revision rates of double plating (DP), single plating using a lateral locking plate (SP), or distal femoral arthroplasty (DFA) for the treatment of periprosthetic distal femur fractures (PDFFs).

The December 2023 Trauma Roundup³⁶⁰ looks at: Distal femoral arthroplasty: medical risks under the spotlight; Quads repair: tunnels or anchors?; Complex trade-offs in treating severe tibial fractures: limb salvage versus primary amputation; Middle-sized posterior malleolus fractures – to fix?; Bone transport through induced membrane: a randomized controlled trial; Displaced geriatric femoral neck fractures; Risk factors for reoperation to promote union in 1,111 distal femur fractures; New versus old – reliability of the OTA/AO classification for trochanteric hip fractures; Risk factors for fracture-related infection after ankle fracture surgery.

We investigated the long-term changes in the Harris Hip and Knee Society scores (HSS and KSS) to determine whether they result from overall functional decline rather than actual changes in the condition of the prosthesis. The HHS for 106 total hip arthroplasties with a minimum follow-up of ten years, no medical complications after operation and no evidence of radiological loosening, and the KSS for 264 total knee arthroplasties with a minimum follow-up of 12 years and no medical complications after operation or signs of radiographical loosening were evaluated. There were statistically significant drops in the functional scoring components of the joint evaluation systems despite no loosening of the prostheses or other significant medical complications. The HHS declined at an average of 0.67 points per year from between three and ten years after operation (p < 0.0001). Contributing to this were deterioration in gait and limp (p < 0.0004), the use of support aids (p < 0.0001), the distance walked (p < 0.0001) and the ability to climb stairs (p < 0.0455). The functional component of the KSS declined significantly at an average 0.88 points per year betwen the third and 12th years (p < 0.0001). There were significant declines in every component of the functional score including the distance walked (p < 0.0001), the ability to climb stairs (p < 0.0001) and the use of support aids (p < 0.0001). The knee score component of the KSS did not decline significantly (p < 0.9750). The combination of functional and pain scores within the HHS system leads to an inaccurate decline in the entire score. The decline of HHS and Knee Society functional scores in total joint arthroplasties, in the absence of implant-related problems, suggests that deterioration in the functional capacity of ageing patients is an important factor in longitudinal studies using these scoring systems

The surgical treatment of unicompartmental knee osteoarthritis remains controversial. This study aims to compare the medium-term outcomes of age and gender matched patients treated with unicompartmental knee replacement (UKR) and total knee replacement (TKR). We retrospectively reviewed pain, function and total knee society scores (KSS) for every UKR and age and gender matched TKR in NHS Tayside, with up to 10 years prospective data from Tayside Arthroplasty Audit Group. KSS was compared at 1, 3 and 5 years. Medical complications and joint revision were identified. Kaplan-Meier with revision as end-point was used for implants survival analysis. 602 UKRs were implanted between 2001 and 2013. Preoperative KSS for pain and total scores were not significantly different between UKRs and TKRs whereas preoperative function score was significantly better for UKRs. Function scores remained significantly better in UKRs from preoperative until 3 years follow up. Further analysis revealed no statistically significant difference in the change of function scores in both groups over time. There was a trend for TKRs to perform better than UKRs in pain scores. Total KSS for both groups were not significantly different at any point of the 5-year study. Fewer medical complications were reported in the UKR group. Kaplan-Meier analysis showed a survival rate of 93.7% in UKRs and of 97% in TKRs (Log rank p-value = 0.012). The revision rate for UKR was twice as much as TKR. The theoretical advantages of UKR are not borne out by the findings in this study other than immediate postoperative complications

Aims

Periprosthetic fractures (PPFs) around the knee are challenging injuries. This study aims to describe the characteristics of knee PPFs and the impact of patient demographics, fracture types, and management modalities on in-hospital mortality.

Aims. To compare the outcomes for trochanteric fractures treated with a sliding hip screw (SHS) or a cephalomedullary nail. Patients and Methods. A total of 400 patients with a trochanteric hip fracture were randomised to receive a SHS or a cephalomedullary nail (Targon PFT). All surviving patients were followed up to one year from injury. Functional outcome was assessed by a research nurse blinded to the implant used. Results. Recovery of mobility, as assessed by a mobility scale, was superior for those treated with the intramedullary nail compared with the SHS at eight weeks, three and nine months (p-values between 0.01 and 0.04), the difference at six and 12 months was not statistically significant (p = 0.15 and p = 0.18 respectively). The mean difference was around 0.4 points (0.3 to 0.5) on a nine point scale. Surgical time for the nail was four minutes less than that for the SHS (p < 0.001). Fracture healing complications were similar for the two groups. There were no statistically significant differences between implants for any other recorded outcomes including the need for post-operative blood transfusion, wound healing complications, general medical complications, hospital stay or mortality. Conclusion. This study confirms the findings of a previous study that both methods of treatment produce similar results, although intramedullary fixation does result in marginally improved regain of mobility in comparison with the SHS. Cite this article: Bone Joint J 2017;99-B:1210–15

Aims

Post-traumatic periprosthetic acetabular fractures are rare but serious. Few studies carried out on small cohorts have reported them in the literature. The aim of this work is to describe the specific characteristics of post-traumatic periprosthetic acetabular fractures, and the outcome of their surgical treatment in terms of function and complications.

Aims

The number of revision arthroplasties being performed in the elderly is expected to rise, including revision for infection. The primary aim of this study was to measure the treatment success rate for octogenarians undergoing revision total hip arthroplasty (THA) for periprosthetic joint infection (PJI) compared to a younger cohort. Secondary outcomes were complications and mortality.

Aims

Despite limited clinical scientific backing, an additional trochanteric stabilizing plate (TSP) has been advocated when treating unstable trochanteric fractures with a sliding hip screw (SHS). We aimed to explore whether the TSP would result in less post operative fracture motion, compared to SHS alone.

Aims

The aims of this study were to determine the incidence and factors for developing periprosthetic joint infection (PJI) following hemiarthroplasty (HA) for hip fracture, and to evaluate treatment outcome and identify factors associated with treatment outcome.

Aims

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

Aims

The use of multimodal non-opioid analgesia in hip fractures, specifically acetaminophen combined with non-steroidal anti-inflammatory drugs (NSAIDs), has been increasing. However, the effectiveness and safety of this approach remain unclear. This study aimed to compare postoperative outcomes among patients with hip fractures who preoperatively received either acetaminophen combined with NSAIDs, NSAIDs alone, or acetaminophen alone.

Introduction. Hypoalbuminemia has previously been identified as an independent predictor of postoperative complications following total knee arthroplasty (TKA). Given the morbidity and financial burden associated with TKA complications, significant effort has gone into identifying patients at increased risk for perioperative complications. The American Society of Anesthesiologists (ASA) physical status score has been utilized for risk stratification of surgical patients for many years and is a measure of overall health. However, it is unclear how measures like albumin compare to the prognostic ability of this type of global health measure. This study aims to elucidate the utility of preoperative albumin compared with that of the ASA score in predicting complications following TKA. Methods. Patients undergoing TKA between 2005 and 2015 were identified using the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database. Patients were stratified based on preoperative hypoalbuminemia (<3.5 g/dL) and ASA score (≤ 2 vs. > 2). Multivariable regression analysis adjusted for age, sex, BMI, and smoking status was utilized to determine predictive potential of hypoalbuminemia and ASA score on each postoperative complication. Results. Of the 79,661 patients included in the cohort, 4.3% had preoperative hypoalbuminemia. Univariate regression analysis found significant predictive abilities of both serum albumin and ASA score on numerous postoperative complications, such as superficial infection, deep infection, MI, pneumonia, renal insufficiency, reintubation, transfusion, readmission, reoperation, and death. Interestingly, multivariable regression analysis demonstrated that hypoalbuminemia more robustly predicted postoperative deep infection than ASA. Discussion and Conclusion. Hypoalbuminemia and ASA each individually predict numerous postoperative complications following TKA. However, this study suggests that while ASA score more accurately predicts post-operative medical complications, hypoalbuminemia may be a more accurate predictor of periprosthetic infection following TKA. Ultimately, preoperative albumin should be incorporated in the pre-operative work-up routine to stratify patient risk, especially regarding postoperative infection

Aims

Two-stage exchange revision total hip arthroplasty (THA) performed in case of periprosthetic joint infection (PJI) has been considered for many years as being the gold standard for the treatment of chronic infection. However, over the past decade, there have been concerns about its safety and its effectiveness. The purposes of our study were to investigate our practice, collecting the overall spacer complications, and then to analyze their risk factors.

The August 2024 Research Roundup³⁶⁰ looks at: Effect of vitamin D deficiency on periprosthetic joint infection and complications after primary total joint replacement; Postoperative angiotensin receptor blocker use associated with decreased rates of manipulation under anaesthesia in patients undergoing total knee arthroplasty; Central sensitization: the missing link between psychological distress and poor outcome following primary total knee arthroplasty; Thromboprophylaxis for the trauma and orthopaedic surgeon; Life expectancy after treatment of metastatic bone disease: an international trend analysis.

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

The June 2024 Hip & Pelvis Roundup³⁶⁰ looks at: Machine learning did not outperform conventional competing risk modelling to predict revision arthroplasty; Unravelling the risks: incidence and reoperation rates for femoral fractures post-total hip arthroplasty; Spinal versus general anaesthesia for hip arthroscopy: a COVID-19 pandemic- and opioid epidemic-driven study; Development and validation of a deep-learning model to predict total hip arthroplasty on radiographs; Ambulatory centres lead in same-day hip and knee arthroplasty success; Exploring the impact of smokeless tobacco on total hip arthroplasty outcomes: a deeper dive into postoperative complications.

The June 2023 Hip & Pelvis Roundup³⁶⁰ looks at: Machine learning to identify surgical candidates for hip and knee arthroplasty: a viable option?; Poor outcome after debridement and implant retention; Can you cement polyethylene liners into well-fixed acetabular shells in hip revision?; Revision stem in primary arthroplasties: the Exeter 44/0 125 mm stem; Depression and anxiety: could they be linked to infection?; Does where you live affect your outcomes after hip and knee arthroplasties?; Racial disparities in outcomes after total hip arthroplasty and total knee arthroplasty are substantially mediated by socioeconomic disadvantage both in black and white patients.

Aims

Ankle fractures are common injuries and the third most common fragility fracture. In all, 40% of ankle fractures in the frail are open and represent a complex clinical scenario, with morbidity and mortality rates similar to hip fracture patients. They have a higher risk of complications, such as wound infections, malunion, hospital-acquired infections, pressure sores, veno-thromboembolic events, and significant sarcopaenia from prolonged bed rest.

The August 2023 Children’s orthopaedics Roundup³⁶⁰ looks at: DDH: What can patients expect after open reduction?; Femoral head deformity associated with hip displacement in non-ambulatory cerebral palsy; Bony hip reconstruction for displaced hips in patients with cerebral palsy: is postoperative immobilization indicated?; Opioid re-prescriptions after ACL reconstruction in adolescents are associated with subsequent opioid use disorder; Normative femoral and tibial lengths in a modern population of USA children; Retrospective analysis of associated anomalies in 636 patients with operatively treated congenital scoliosis; Radiological hip shape and patient-reported outcome measures in healed Perthes’ disease; Significantly displaced adolescent posterior sternoclavicular joint injuries.

Aims

Fractures of the humeral shaft represent 3% to 5% of all fractures. The most common treatment for isolated humeral diaphysis fractures in the UK is non-operative using functional bracing, which carries a low risk of complications, but is associated with a longer healing time and a greater risk of nonunion than surgery. There is an increasing trend to surgical treatment, which may lead to quicker functional recovery and lower rates of fracture nonunion than functional bracing. However, surgery carries inherent risk, including infection, bleeding, and nerve damage. The aim of this trial is to evaluate the clinical and cost-effectiveness of functional bracing compared to surgical fixation for the treatment of humeral shaft fractures.

Aims

Tobacco, in addition to being one of the greatest public health threats facing our world, is believed to have deleterious effects on bone metabolism and especially on bone healing. It has been described in the literature that patients who smoke are approximately twice as likely to develop a nonunion following a non-specific bone fracture. For clavicle fractures, this risk is unclear, as is the impact that such a complication might have on the initial management of these fractures.

The August 2023 Knee Roundup³⁶⁰ looks at: Curettage and cementation of giant cell tumour of bone: is arthritis a given?; Anterior knee pain following total knee arthroplasty: does the patellar cement-bone interface affect postoperative anterior knee pain?; Nickel allergy and total knee arthroplasty; The use of artificial intelligence for the prediction of periprosthetic joint infection following aseptic revision total knee arthroplasty; Ambulatory unicompartmental knee arthroplasty: development of a patient selection tool using machine learning; Femoral asymmetry: a missing piece in knee alignment; Needle arthroscopy – a benefit to patients in the outpatient setting; Can lateral unicompartmental knees be done in a day-case setting?

Aims

Medial unicompartmental knee arthroplasty (mUKA) is an advised treatment for anteromedial knee osteoarthritis. While long-term survival after mUKA is well described, reported incidences of short-term surgical complications vary and the effect of surgical usage on complications is less established. We aimed to describe the overall occurrence and treatment of surgical complications within 90 days of mUKA, as well as occurrence in high-usage centres compared to low-usage centres.

Aims

Contemporary outcomes of primary total hip arthroplasties (THAs) with highly cross-linked polyethylene (HXLPE) liners in patients with inflammatory arthritis have not been well studied. This study examined the implant survivorship, complications, radiological results, and clinical outcomes of THA in patients with inflammatory arthritis.

Aims. Surgical site infection (SSI) is a common complication of surgery with an incidence of about 1% in the United Kingdom. Sutures can lead to the development of a SSI, as micro-organisms can colonize the suture as it is implanted. Triclosan-coated sutures, being antimicrobical, were developed to reduce the rate of SSI. Our aim was to assess whether triclosan-coated sutures cause a reduction in SSIs following arthroplasty of the hip and knee. Patients and Methods. This two-arm, parallel, double-blinded study involved 2546 patients undergoing elective total hip (THA) and total knee arthroplasty (TKA) at three hospitals. A total of 1323 were quasi-randomized to a standard suture group, and 1223 being quasi-randomized to the triclosan-coated suture group. The primary endpoint was the rate of SSI at 30 days postoperatively. Results. The baseline characteristics of age, gender and comorbidities were well matched in the two groups. The rates of superficial SSI were 0.8% in the control group and 0.7% in the intervention group (p = 0.651), and when deep and superficial SSIs were combined the rates were 2.5% and 1.8 (p = 0.266). The length of stay in hospital and the rates of medical complications did not differ significantly between the groups (p = 1.000). Conclusion. This trial provided no evidence that the use of triclosan-coated sutures at THA and TKA leads to a reduction in the rate of SSI. Cite this article: Bone Joint J 2018;100-B:296–302

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Hyaline cartilage has a low capacity for regeneration. Untreated osteochondral lesions of the femoral head can lead to progressive and symptomatic osteoarthritis of the hip. The purpose of this study is to analyze the clinical and radiological long-term outcome of patients treated with osteochondral autograft transfer. To our knowledge, this study represents a series of osteochondral autograft transfer of the hip with the longest follow-up.

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Arthroplasties of the elbow, including total elbow arthroplasty, radial head arthroplasty, distal humeral hemiarthroplasty, and radiocapitellar arthroplasty, are rarely undertaken. This scoping review aims to outline the current research in this area to inform the development of future research.

Aim. Circular frames are used to treat a wide spectrum of acute injuries and deformities. We report on our experience of treating both acute and chronic trimalleolar fracture dislocations with a closed technique, utilizing fine wires and a circular frame. Methods. Data was collected from all patients treated for either acute or chronic trimalleolar fracture dislocations at a single centre between January 2016 and December 2017. A total of 10 patients were identified, 8 with acute injuries and 2 with chronic/delayed injuries. Clinical and radiological outcomes were recorded, as well as patient reported outcome measures (PROMs) using the Chertsey Outcome Score for Trauma (COST score). Results. 8 patients were treated for acute trimalleolar fractures, 2 of which were open medially. One patient had sustained a further break and metalwork failure following fixation for trimalleolar fracture at another hospital and 1 patient presented 6 weeks post injury. Average age was 53.6 years (range 20–86). Average time to surgery following acute injury was 4.3 days (0–12). Average follow up to date was 25 weeks (2–60). All patients had satisfactory alignment and union at completion of treatment. The average COST score (n=8) was 52/100 (30–90). 3 patients had pin site infections managed with antibiotics. One patient died due to unrelated medical complications. Conclusion. Initial use of circular frames for trimalleolar fracture has shown excellent results in terms of radiological, clinical and patient reported outcome measures. Complications have been limited to date

Aims. Postoperative complication rates remain relatively high after adult spinal deformity (ASD) surgery. The extent to which modifiable patient-related factors influence complication rates in patients with ASD has not been effectively evaluated. The aim of this retrospective cohort study was to evaluate the association between modifiable patient-related factors and complications after corrective surgery for ASD. Methods. ASD patients with two-year data were included. Complications were categorized as follows: any complication, major, medical, surgical, major mechanical, major radiological, and reoperation. Modifiable risk factors included smoking, obesity, osteoporosis, alcohol use, depression, psychiatric diagnosis, and hypertension. Patients were stratified by the degree of baseline deformity (low degree of deformity (LowDef)/high degree of deformity (HighDef): below or above 20°) and age (Older/Younger: above or below 65 years). Complication rates were compared for modifiable risk factors in each age/deformity group, using multivariable logistic regression analysis to adjust for confounders. Results. A total of 480 ASD patients met the inclusion criteria. By two years, complication rates were 72% ≥ one complication, 28% major, 21% medical, 27% surgical, 11% major radiological, 8% major mechanical, and 22% required reoperation. Younger LowDef patients with osteoporosis were more likely to suffer either a major mechanical (odds ratio (OR) 5.9 (95% confidence interval (CI) 1.1 to 36.9); p = 0.048) or radiological complication (OR 7.0 (95% CI 1.9 to 25.9); p = 0.003). Younger HighDef patients were much more likely to develop complications if obese, especially major mechanical complications (OR 2.8 (95% CI 1.1 to 8.6); p = 0.044). Older HighDef patients developed more complications when diagnosed with depression, including major radiological complications (OR 3.5 (95% CI 1.1 to 10.6); p = 0.033). Overall, a diagnosis of depression proved to be a risk factor for the development of major radiological complications (OR 2.4 (95% CI 1.3 to 4.5); p = 0.005). Conclusion. Certain modifiable patient-related factors, especially osteoporosis, obesity, and mental health status, are associated with an increased risk of complications after surgery for spinal deformity. Surgeons should look for these conditions when assessing a patient for surgery, and optimize them to the fullest extent possible before proceeding to surgical correction so as to minimize the prospect of postoperative morbidity. Cite this article: Bone Joint J 2022;104-B(11):1249–1255

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Breast cancer survivors have known risk factors that might influence the results of total hip arthroplasty (THA) or total knee arthroplasty (TKA). This study evaluated clinical outcomes of patients with breast cancer history after primary THA and TKA.

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Professional dancers represent a unique patient population in the setting of hip arthroplasty, given the high degree of hip strength and mobility required by their profession. We sought to determine the clinical outcomes and ability to return to professional dance after total hip arthroplasty (THA) or hip resurfacing arthroplasty (HRA).

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The Birmingham Hip Resurfacing (BHR) was introduced in 1997 to address the needs of young active patients using a historically proven large-diameter metal-on-metal (MoM) bearing. A single designer surgeon’s consecutive series of 130 patients (144 hips) was previously reported at five and ten years, reporting three and ten failures, respectively. The aim of this study was to extend the follow-up of this original cohort at 25 years.

Introduction. Femoral neck fractures are an increasingly common injury in the elderly. Frequently these patients present taking Clopidogrel, an irreversible inhibitor of platelet aggregation. Although this is associated with an increased risk of intra-operative bleeding and also an increased risk of spinal haematoma where regional anaesthesia is employed, the recent SIGN (Scottish Intercollegiate Guidance Network) guidelines recommend that surgery should not be delayed. Methods. We conducted a retrospective review of consecutive patients admitted with femoral neck fractures between April 2008 and October 2009. Patients on Clopidogrel were identified and data including ASA grade, time to operation, medical co-morbidities, and post-admission complications were recorded. Comparative information from the National Hip Fracture Database was used. Results. 405 patients were included. 27 patients were taking Clopidogrel on admission and they were mainly ASA 3 or 4. Mean time to theatre was 8 days. Post-admission medical complications occurred in 7 patients (25.9%). A further 4 patients (14.8%) died, 3 of them postoperatively. From the study population a control group of 72 ASA 3 and 4 patients was further studied. The mean time to operation was 2.3 days. Post-admission medical complications occurred in 13 patients (18%) and 8 patients (11%) died postoperatively. In 2009 the national mean time to operation was 2.19 days with an associated mortality rate of 8.67%. Discussion and Conclusion. Patients receiving Clopidogrel have complex medical co-morbidities and a higher anaesthetic risk. Delaying operative management might be contributing to the increased rate of mortality and morbidity. In accordance with the SIGN guidelines we recommend early operative intervention in these high risk patients

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To evaluate if, for orthopaedic trainees, additional cadaveric simulation training or standard training alone yields superior radiological and clinical outcomes in patients undergoing dynamic hip screw (DHS) fixation or hemiarthroplasty for hip fracture.

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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. Aged trauma patients with proximal femur fractures are prone to various complications. They may be associated with their comorbidities which also need to be adressed. These complications limit the patient”s postoperative health status and subsequently their activity and independency. As an attempt to improve the postoperative management of aged hip fracture patients a better understanding of the postoperative condition in these patients is necessary. Therefore, this meta-analysis is intended to provide an overview of postoperative complications in the elderly hip fracture patients and to improve the understanding of an adequate postoperative management. Material and method. Medline was used to screen for studies reporting on the complication rates of hip fracture patients > 65 years. The search criteria were: “proximal femur fracture, elderly, complication”. In addition to surgical studies, internal medicine and geriatric studies were also included. Randomized studies, retrospective studies as well as observation studies were included. Furthermore, reoperation rates as well as treatment-related complications were recorded. The 1-year mortality was calculated as outcome parameter. Results. Overall 54 studies were enrolled, published between 2011 and 2016. The mean age of the 9812 patients was 81 years (65–99 years). Follow-up was at least one year. The reoperation rate after osteosynthesis of pertrochanteric femur fractures was 8.7%. The reoperation rate was dependent on the type of fracture and the surgical method. Pneumonia (9,5%) and urinary tract infections (27%) were the most common postoperative infections. With 23%, delirium was one of the most common medical complications. The 1-year mortality rate was 18.7%. Conclusion. Orthogeriatric patients represent a complex patient population. Addressing the special needs of elderly patients reduces postoperative complications. Establishing comanagement or orthogeriatric wards can also be helpful to manage comorbidities and postoperative complications. It is important to not only choose the proper surgical procedure but to monitor orthogeriatric patients closely during their hospitalization

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

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

Purpose: Acetabular fractures in elderly patients are difficult problems with various treatment options. Our institution treats many of these patients with percutaneous acetabular fixation. We reviewed medical records and contacted patients to determine the rate of conversion to total hip arthroplasty. Method: Our institutional trauma database was searched for all patients age 60 and older who had been treated with percutaneous screw fixation for an acetabular fracture. Seventy-nine consecutive patients (80 fractures) were identified. Medical records were examined to obtain peri-operative and follow-up information regarding the hospital course and conversion to total hip arthroplasty. A survivorship anaylsis was created with conversion to total hip arthroplasty as the censored event, and standard Kaplan-Meier curves were constructed. Five categorical variables were used to test for differences in survival of the native hip: age, sex, simple versus complex fracture pattern, closed versus limited open reduction, and occurrence of a medical complication. Results: Seventy-five fractures had adequate clinical follow-up with a mean of 3.9 years (range 0.5 – 11.9 years). Average blood loss was 69 cc and there were no postoperative infections. 19/75 (25%) were converted to total hip arthroplasty at a mean time of 1.4 years after the index procedure. Survivorship analysis demonstrated a cumulative survival of 65% at 11.9 years of follow-up. There were no conversions to arthroplasty beyond 4.7 post-operatively. There were no statistically significant associations between conversion to arthroplasty and age, sex, closed versus limited open reduction, simple versus complex fracture pattern, and occurrence of a medical complication. Conclusion: Percutaneous fixation is a viable treatment option for patients age 60 or greater with acetabular fractures. Rates of conversion to total hip arthroplasty are comparable to other treatment methods and if conversion is required, soft tissues are preserved for future surgery

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The aim of this study was to describe the management and associated outcomes of patients sustaining a femoral hip periprosthetic fracture (PPF) in the UK population.

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The aim of this study was to investigate the rate of revision for distal femoral arthroplasty (DFA) performed as a primary procedure for native knee fractures using data from the Australian Orthopaedic Association National Joint Arthroplasty Registry (AOANJRR).

Introduction. Orthopaedic surgeons are frequently asked to perform a revision total hip arthroplasty (THA) in patients over 80 years of age. Our objective was to evaluate the outcomes after revision THA in patients 80 years or older and compare them to a cohort of patients less than 80 years of age. Methods. We reviewed all revision THAs performed in our institution from 3/1996 to 12/2008. We compared intra- and post-operative complications (medical and orthopaedic), mortality, clinical outcomes and patient satisfaction between the two age groups. Peri-operative information and complications were collected prospectively, and clinical outcome data were obtained both pro- and retrospectively. The Merle d'Aubigné score, Harris Hip score, general health (SF-12) and patient satisfaction (visual analog scale) were assessed. Results. Overall, 325 revision THAs were included, 84 (25.8%) in patients 80 years and 241 in patients <80 years. In both groups the reason for revision was aseptic loosening in 62% of the patients (mean interval primary THA - revision 142 vs. 97 months). The older group was more often revised for periprosthetic fractures and recurrent dislocation. Mean follow-up time was 4.3 years. Mortality (80 vs. <80 years) was 6% vs. 0% 3 months postoperative, 9.5% vs. 1.2% 1 year postoperative, and 31% vs. 8.3% 5 years postoperative. 3 (3.6%) re-revisions were performed in patients 80 years compared to 24 (10%) in the younger group. Postoperative medical complications developed in 22.6% compared to 6.6% in the younger group. There were one infection and 13 dislocations in patients 80 years vs. 12 infections and 22 dislocations in the other group. The Merle d'Aubigné score improved from 9.6 to 13.7 (p=0.001) in patients 80 years or older vs. 10.3 to 14.3 (p<0.001), and the Harris Hip score at last follow-up was 74.2 vs. 78.5. Patient satisfaction was significantly higher in the older group (8.4 vs. 7.5, mean difference 0.9, 95% CI 0.2;1.8). Conclusion. Revision THA in patients over 80 years was associated with substantial clinical improvement, and patient satisfaction was greater than among the younger group. However, the medical complication rate and the 3-months-mortality were substantially higher

This study reviews Total Hip Arthroplasty (THA) in the subcapital femoral neck fracture population looking at early complications. Primary THA’s performed in our institution for femoral neck fractures between 1999 and 2001 were reviewed. The case records were obtained from the hospital patient information database. Medical charts, including operation and outpatient notes, were used to obtain information on the level of experience of the surgeon, supervision and complications. Sixty five THA’s were performed on 65 patients with the average age of 77. Trainee Registrars performed 62%, 15% with a consultant assistant and consultants performed 38%. There were 19 (30%) medical complications giving a total complication incidence of 38%. All of the procedures were performed via the Hardinge direct lateral approach. There were 6 (9%) surgical complications, including one deep infection requiring revision. There were no dislocations or peri-operative deaths. The one-year mortality was 9% (equal to expected mortality of age related population without fracture). Primary THA’s for displaced subcapital fracture in “community ambulators” is a safe and reliable procedure with an acceptable rate of surgical complications. Although there were a large number of minor medical complications documented, the 12-month mortality for this group remained the same as the population normal

Aim: To identify the significant risk factors that influence patient mortality and morbidity in the management of displaced subcapital neck of femur fractures in independent elderly patients (aged > 70 years) managed with total hip arthroplasty through a modified Hardinge approach. Methods: Thirty-seven primary hip arthroplasties performed for displaced fractures of the neck of femur in “Healthcare Hawkes Bay” between 1998 and 2000 were reviewed. The surgery was carried out by one surgeon (VP), using a modified lateral approach. The patients’ records were screened for outcomes and complications. An independent review was made (DA, NW) using the modified Harris hip score. Results: The average age of the patients was 85 years (range: 70 to 92 years). At an average of 1.8 years (12 months to 24 months), no patient had suffered a dislocation or had needed another operation on the hip. The majority of the patients were satisfied with the outcome. However, there were significant medical complications (total of 38 complication in 22 patients). There were two deaths in the first 12 months. Conclusions: The incidence of dislocation and a reduced revision rate can be achieved with a modified lateral approach (Hardinge). However, aggressive treatment is necessary before and after the surgery, as there is high incidence of medical complications. The number of existing medical conditions at the date of admission to hospital was a significant factor influencing patient morbidity

The June 2012 Trauma Roundup. 360. looks at: nerve injuries of warfare; the medical complications of earthquakes; the measuring of tissue pressures in compartment syndrome; the risk of plunging through the bone when drilling; bony nonunion and negative pressure therapy; surgery for the posteriorly dislocated hip; whether to use the sliding screw or intramedullary nail for the trochanteric fracture; antegrade interlocking nailing for the distal femoral fracture; and gunshot wounds to the pancreas

Introduction and purpose: Cases of unstable extracapsular fractures of the proximal femur should be treated by endomedullary nailing; the PFN (Synthes) nail has proved to be a good option for this approach. The purpose of our paper is to make a descriptive study analyzing the medical and technical complications derived from the use of the PFN nail. Materials and methods: This study reviews a consecutive series of 432 patients implanted with a PFN, out of whom 352 have had a follow-up longer than 6 months. Mean age is 76.3 years and the male/female ratio is 2:1. An analysis was made of the variables related to medical complications inherent in the fracture itself and in the patient characteristics (AO fracture type, ASA surgical risk, organic complications, infection risk factors, duration of hospital stay and mortality) and to secondary mechanical complications caused by implant design or the surgical technique chosen (implant protrusions, system cutting out, osteolysis and intraoperative and postoperative fractures propagated from the tip of the implant). Results: We performed a frequency analysis and an exponential chi square study which told us that the most frequent fracture was type A2 (AO classification) and the most frequent patient type was ASA III (ASA classification). Mean hospital stay was 6.66 days. During follow-up, medical complications were 17.5% and mechanical ones 11%. Conclusions: The PFN nail is an efficient means for treating extracapsular fractures of the proximal femur although its use is not free from complications, which could be minimized by employing a careful surgical technique. We found that there is a direct relationship between surgical success and patient ASA type

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Total hip arthroplasty (THA) is one of the most successful surgical procedures. The objectives of this study were to define whether there is a correlation between socioeconomic status (SES) and surgical complications after elective primary unilateral THA, and investigate whether access to elective THA differs within SES groups.

Background: Nonagenarian patients with hip fractures present many challenges to the clinician, both in terms of their advanced age and medical co-morbidities with potential orthopaedic complications. Our aims were to assess outcome of hip fractures in a nonagenarian population with respect to pre-operative predictors of outcome, immediate and long-term morbidity, and survival rates. Methods: All nonagenarian patients with a hip fracture admitted to our unit between January 2000 and Decem-ber 2003 were considered. Eighty-one patients were included, the majority being female (M: F 14: 67). Ages ranged from 90 to 98 years for female patients (mean 92.5 years, SD 2.2) compared to 90 to 95 years for male patients (mean 92.7 years, SD 2). Results: Delay to surgery was 1.25 days and the median ASA grade was III. The method of anaesthesia used was spinal in 78% and general in 22%. The majority of patients had intertrochanteric fractures and methods of fixation involved internal fixation in 63% and hemiarthroplasty in the remaining 36% of the group deemed fit for surgery. The rate of complications during inpatient stay was 19% and there were eight in-patient post-operative mortalities due to medical complications. Mean survival post hip fracture in our patient group was 474.7 days (median 372.5 days). Within forty days of surgery 25% of patients died, including our inpatient mortality of 10%. However, 50% of the patients were still alive 126 days post-operatively. Conclusion: Hip fractures must be given special attention in the nonagenarian population because of their advanced age and medical co-morbidities. 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. Lower ASA grades, surgery within 48 hours, and increased pre-operative haemoglobin levels were all associated with favourable outcomes. Medical complications were the major cause of morbidity and mortality with a low rate of orthopaedic complications. The majority of patients were able to return to their previous residence and continued to be mobile with various levels of assistance

Proximal femur fractures are increasing in prevalence, with femoral neck (FN) and intertrochanteric (IT) fractures representing the majority of these injuries. The salvage procedure for failed open reduction internal fixation (ORIF) is often a conversion to total hip arthroplasty (THA). The use of THA for failed ORIF improves pain and function, however the procedure is more challenging. The aim of this study was to investigate the clinical and radiographic outcomes in patients who have undergone THA after ORIF. This retrospective case-control study compared patients who underwent THA after failed ORIF to a matched cohort undergoing primary THA for non-traumatic osteoarthritis. From 2004 to 2014, 40 patients were identified. The matched cohort was matched for date of operation, age, gender, and type of implant. Preoperative, intraoperative, and postoperative data were collected and statistical analysis was performed. The cohort of patients with a salvage THA included 18 male and 22 female patients with a mean age of 73 years and mean follow up of 3.1 years. Those with failed fixation included 12 IT fractures and 28 FN fractures. The mean time between ORIF and THA was 2.1 years for IT fractures and 8.5 years for FN fractures (p=0.03). The failed fixation group had longer procedures, greater drop in hemoglobin, and greater blood transfusion rate (p<0.05). There was one revision and one dislocation in the failed fixation group with no revisions or dislocations in the primary THA group. Length of admission, medical complications, and functional outcome as assessed with a standardised hip score and were found not to be statistically different between the groups. Salvage THA for failed initial fixation of proximal femur fractures yields comparable clinical results to primary THA with an increased operative time, blood loss, and blood transfusion rate

Implant choice was changed from cemented Thompson to Exeter Trauma Stem (ETS) for treatment of displaced intra-capsular neck of femur fractures in University Hospital Aintree, Liverpool, United Kingdom (a major trauma center), following the NICE guidelines that advised about the use of a proven femoral stem design rather than Austin Moore or Thompson stems for hemiarthroplasties. The aim of our study was to compare the results of Thompson versus ETS hemiarthroplasty in Aintree. We initially compared 100 Thompson hemiarthroplasties that were performed before the start of ETS use, with 100 ETS hemiarthroplasties. There was no statistically significant difference between the two groups in terms of patients' demographics (age, sex and ASA grade), intra-operative difficulties/complications, post op medical complications, blood transfusion, in-patient stay and dislocations. The operative time was statistically significantly longer in the ETS group (p= .0067). Worryingly, the 30 days mortality in ETS group was more than three times higher in ETS group (5 in Thompson group versus 16 in ETS group. P= .011). To corroborate our above findings we studied 100 more consecutive patients that had ETS hemiarthroplasty. The results of this group showed 30 day mortality of 8 percent. However the operative time was again significantly longer (p= .003) and there was 18 percent conversion to bipolar hemiarthropalsty. Moreover there was statistically significant increased rate of deep infection (7%, p = .03) and blood transfusion (27%, p = .007). This we feel may be due to longer and more surgically demanding operative technique including pressurised cementation in some patients with significant medical comorbidities. Our results raise the question whether ETS hemiarthoplasty implant is a good implant choice for neck of femur fracture patients. Randomised control trials are needed to prove that ETS implant is any better than Thompson hemiarthroplasty implants in this group of patients

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).