Background

Frequency of primary total hip (THA) and total knee (TKA) arthroplasty procedures is increasing, with a subsequent rise in revision procedures. This study aims to describe timing and excess surgical mortality associated with revision THA and TKA compared to those on the waiting list.

Aims. To address the natural history of severe post-tuberculous (TB) kyphosis, with focus upon the long-term neurological outcome, occurrence of restrictive lung disease, and the effect on life expectancy. . Patients and Methods. This is a retrospective clinical review of prospectively collected imaging data based at a single institute. A total of 24 patients of Southern Chinese origin who presented with spinal TB with a mean of 113° of kyphosis (65° to 159°) who fulfilled inclusion criteria were reviewed. Plain radiographs were used to assess the degree of spinal deformity. Myelography, CT and MRI were used when available to assess the integrity of the spinal cord and canal. Patient demographics, age of onset of spinal TB and interventions, types of surgical procedure, intra- and post-operative complications, and neurological status were assessed. . Results. All except one of the 24 patients were treated with anti-TB chemotherapy when they were first diagnosed with spinal TB. They subsequently received surgery either for neurological deterioration, or deformity correction in later life. The mean follow-up was 34 years (11 to 59) since these surgical interventions. Some 16 patients (66.7%) suffered from late neurological deterioration at a mean of 26 years (8 to 49) after the initial drug treatment. The causes of neurological deterioration were healed disease in nine patients (56.2%), re-activation in six patients (37.5%) and adjacent level spinal stenosis in one patient (6.3%). The result of surgery was worse in healed disease. Eight patients without neurological deterioration received surgery to correct the kyphosis. The mean correction ranged from 97° to 72°. Three patients who were clinically quiescent with no neurological deterioration were found to have active TB of the spine. Solid fusion was achieved in all cases and no patient suffered from neurological deterioration after 42 years of follow-up. On final follow-up, six patients were noted to have deceased (age range: 47 years to 75 years). Conclusion. Our study presents one of the longest assessments of spinal TB with severe kyphosis. Severe post-TB kyphosis may lead to significant health problems many years following the initial drug treatment. Early surgical correction of the kyphosis, solid fusion and regular surveillance may avoid late complications. Paraplegia, restrictive lung disease and early onset kyphosis might relate to early death. Clinically quiescent disease does not mean cure. . Cite this article: Bone Joint J 2017;99-B:1381–8

Abstract. Introduction. There is paucity of evidence in predicting outcomes following cervical decompression in patients in octogenerians with cervical myelopathy. Our aim is to analyse the predictive value of Charlson comorbidity index (CCI) on clinical outcomes in this group. Methods. All patients age >80 years who underwent cervical decompression+/−stabilisation between January 2006-December 2021 at University Hospitals of Derby & Burton were included. Logistic regression analysis was performed using JASP. Results. Total 72 patients (n=32 male, n=28 female). Mean age 83.44 ± 3.21 years. 67 patients underwent posterior decompression+ stabilisation & 5 patients had posterior decompression alone. Mean CCI was 5; graded moderate in 32 (44%, CCI=<4) and severe in 40 (55.5%, CCI>4). Mean age and preoperative Nurick grade was similar between moderate and severe groups. Postoperative Nurick grade improved equally in both groups by 0.67 and 0.68 respectively (p=0.403). Mean LOS 16±16.12 days. 5 complications in the moderate group (21.8%) and 8 complications in severe group (21.6%); wound infection (n=7), other infection (n=2), electrolyte derangement (n=2), AKI (n=1), blood transfusion (n=1) and early death (n=3) (p=0.752). 1 early postoperative death <30 days occurred in the moderate group (4.3%) whereas 2 occurred in the severe group (5.3%) (p=0.984). No patients with moderate CCI required nursing home discharge whereas 7.9% of severe patients required this. Conclusion. Both groups benefitted from neurological improvement postoperatively, low 1 year mortality. No difference in hospital stay, complication rate and early mortality between both groups. More patients with severe CCI require nursing care after discharge than those with moderate CCI

Aims. Our primary aim was to assess reoperation-free survival at one year after the index injury in patients aged ≥ 75 years treated with internal fixation (IF) or arthroplasty for undisplaced femoral neck fractures (uFNFs). Secondary outcomes were reoperations and mortality analyzed separately. Methods. We retrieved data on all patients aged ≥ 75 years with an uFNF registered in the Swedish Fracture Register from 2011 to 2018. The database was linked to the Swedish Arthroplasty Register and the National Patient Register to obtain information on comorbidity, mortality, and reoperations. Our primary outcome, reoperation, or death at one year was analyzed using restricted mean survival time, which gives the mean time to either event for each group separately. Results. Overall, 3,909 patients presenting with uFNFs were included. Of these patients, 3,604 were treated with IF and 305 with primary arthroplasty. There were no relevant differences in age, sex, or comorbidities between groups. In the IF group 58% received cannulated screws and 39% hook pins. In the arthroplasty group 81% were treated with hemiarthroplasty and 19% with total hip arthroplasty. At one year, 32% were dead or had been reoperated in both groups. The reoperation-free survival time over one year of follow-up was 288 days (95% confidence interval (CI) 284 to 292) in the IF group and 279 days (95% CI 264 to 295) in the arthroplasty group, with p = 0.305 for the difference. Mortality was 26% in the IF group and 31% in the arthroplasty group at one year. Reoperation rates were 7.1% in the IF group and 2.3% in the arthroplasty group. Conclusion. In older patients with a uFNF, reoperation-free survival at one year seems similar, regardless of whether IF or arthroplasty is the primary surgery. However, this comparison depends on the choice of follow-up time in that reoperations were more common after IF. In contrast, we found more early deaths after arthroplasty. Our study calls for a randomized trial comparing these two methods. Cite this article: Bone Jt Open 2024;5(2):86–92

Aims. The early mortality in patients with hip fractures from bony metastases is unknown. The objectives of this study were to quantify 30- and 90-day mortality in patients with proximal femoral metastases, and to create a mortality prediction tool based on biomarkers associated with early death. Methods. This was a retrospective cohort study of consecutive patients referred to the orthopaedic department at a UK trauma centre with a proximal femoral metastasis (PFM) over a seven-year period (2010 to 2016). The study group were compared to a matched control group of non-metastatic hip fractures. Minimum follow-up was one year. Results. There was a 90-day mortality of 46% in patients with metastatic hip fractures versus 12% in controls (89/195 and 24/192, respectively; p < 0.001). Mean time to surgery was longer in symptomatic metastases versus complete fractures (9.5 days (SD 19.8) and 3.4 days (SD 11.4), respectively; p < 0.05). Albumin, urea, and corrected calcium were all independent predictors of early mortality and were used to generate a simple tool for predicting 90-day mortality, titled the Metastatic Early Prognostic (MEP) score. An MEP score of 0 was associated with the lowest risk of death at 30 days (14%, 3/21), 90 days (19%, 4/21), and one year (62%, 13/21). MEP scores of 3/4 were associated with the highest risk of death at 30 days (56%, 5/9), 90 days (100%, 9/9), and one year (100%, 9/9). Neither age nor primary cancer diagnosis was an independent predictor of mortality at 30 and 90 days. Conclusion. This score could be used to predict early mortality and guide perioperative counselling. The delay to surgery identifies a potential window to intervene and correct these abnormalities with the aim of improving survival. Cite this article: Bone Joint J. 2020;102-B(1):72–81

Objectives: Behind armour blunt trauma (BABT) to the thorax results from motion of the body wall arising from the defeat of high-energy projectiles by body armour. NATO predicts that BABT will increase in future conflicts. This study aims to define biomechanical tolerance levels for BABT to the lateral thorax. Methods: Terminally anaesthetised pigs (n=19) were subjected to 4 levels of severity of BABT (Table). Two types of armour plates were used. Group 1 were subjected to a 7.62 mm round (INIBA armour) whilst group 2 was subjected to a 12.7 mm round (EBA armour) the latter group being further subdivided by the presence or absence of two thicknesses of trauma attenuating backing (TAB). Accelerometers were attached to the pleural aspect of ribs 7, 8 and 9 mid-way between the spine and the sternum. Results: Outcome was assessed by classifying severity of injury, in terms of mortality, into 3 groups – survivors (animals surviving to 6 h post-impact), early (0–30 min) and late deaths (> 30 min–6 h). The peak acceleration values were obtained from the accelerometer closest to the point of impact. Mean peak acceleration was significantly higher in the early death group (1070 km/s. 2. ) compared to survivors (591 km/s. 2. ) (p< 0.05). There were 6 early deaths, 5 late deaths and 8 survivors. In terms of outcome Group 1 represented the lowest threat with 5 survivors and 1 late death. The animals in Group 2 with no TAB fared worst with 2 early deaths, one late death and no survivors. Deaths were due to respiratory failure/apnoea (n=4), pneumothorax (n=2), haemothorax (n=1), respiratory failure/pulmonary contusion (n=3) and ventricular fibrillation (n=1). Conclusions: Peak acceleration of the body wall may be used to rank the outcome following BABT. There is a significant difference in peak acceleration at the extremes of the injury scale

Early mortality in patients with hip fractures due to bony metastases is unknown. The aim was to quantify 30 and 90-day mortality in patients with metastatic hip fractures and identify markers associated with early death. Consecutive patients referred to orthopaedics with a metastatic proximal femoral fracture/impending fracture over a six-year period were compared to a matched control group of non-malignant hip fractures. Minimum follow-up was 1 year and data was analysed using the student´s t-test (significance p<0.05). From Jan 2010-Dec 2015, 163 patients were referred with metastatic proximal femoral lesions. 90-day mortality was three times higher than controls (44% 71/163 vs. 12% 4/33, p<0.01). Mean time from referral to surgery was longer in impending versus completed fractures (11 and 4 days respectively, p<0.05). Multiple biochemical markers were associated with early mortality in the metastatic group. Patients who died early were more likely to demonstrate low haemoglobin and albumin, and high c-reactive protein, platelets, urea, alkaline phosphatase and calcium (p<0.05). Several biochemical markers associated with early mortality reached clinical and statistical significance. These markers were combined into a score out of 7 and indicated a higher early mortality in metastatic patients compared to controls. Patients with a score of 5–6/7 were 31 times more likely to die within 90 days versus controls. This scoring system could be utilised to predict early mortality and guide management. The average delay to surgery of 4 days (completed) and 11 days (impending fractures) identifies a window to intervene and correct these abnormalities to improve survival

Aims

Total femoral arthroplasty (TFA) is a rare procedure used in cases of significant femoral bone loss, commonly from cancer, infection, and trauma. Low patient numbers have resulted in limited published work on long-term outcomes, and even less regarding TFA undertaken for non-oncological indications. The aim of this study was to evaluate the long-term clinical outcomes of all TFAs in our unit.

Aims

National hip fracture registries audit similar aspects of care but there is variation in the actual data collected; these differences restrict international comparison, benchmarking, and research. The Fragility Fracture Network (FFN) published a revised minimum common dataset (MCD) in 2022 to improve consistency and interoperability. Our aim was to assess compatibility of existing registries with the MCD.

There is comprehensive data addressing the 6 to 18-month survival in patients with pathological neck of femur (NOF) fractures due to bony metastases. However, little is known about early mortality in this group. The aim was to quantify 30 and 90-day mortality in patients with pathological NOF lesions/fractures and identify biochemical markers associated with early death. Orthopaedic trauma lists over one year were used to identify patients with a pathological NOF fracture/lesion. 33 patients had a metastatic NOF fracture/lesion and were compared to a control group of age and gender-matched non-pathological NOF fractures. Time from referral to surgery was higher in patients with a pathological fracture compared to a pathological lesion (average 7.4 and 0.6 days, p<0.05). 30 and 90-day mortality was higher in the metastatic group compared to controls (15% 5/33 vs 9% 3/33 p<0.05, and 42% 14/33 vs 12% 4/33 p<0.01, respectively). Patients with early mortality had lower average sodium (135 vs 138, p<0.05), creatinine (48 vs 62, p<0.05) and APTT (27 vs 32, p<0.05). They had a higher average WCC (11.3 vs 7, p<0.05) and CRP (55 vs 18, p<0.01). Metastatic patients with early mortality had lower albumin (20 vs 30, p<0.01) and haemoglobin (102 vs 121, p<0.01), which were higher in the control NOF group with early mortality (albumin 28 and haemoglobin 118 respectively, p<0.05). Patients with pathological NOF lesions have multiple biochemical abnormalities associated with early mortality. A prospective study is proposed to assess whether correction of these abnormalities can improve survival in this group

Aims

Hip fracture commonly affects the frailest patients, of whom many are care-dependent, with a disproportionate risk of contracting COVID-19. We examined the impact of COVID-19 infection on hip fracture mortality in England.

We reviewed the outcome of Agility total ankle replacements carried out in our institution between 2002 and 2006. Follow-up consisted of clinical and radiological review pre-operatively, at 6 weeks, 6 and 12 months, and annually until 10 years post-op. Clinical review included the American Orthopaedic Foot and Ankle Score, satisfaction and pain scores. 30 arthroplasties were performed in 30 consecutive patients. Pre-operative diagnosis was rheumatoid arthritis (16), primary osteoarthritis (12) and post-traumatic osteoarthritis (2). After a mean follow up of 6.2 years (1.4–10.1), 4 patients had died, and 20 out of the remaining 24 were available for follow-up. Complications included lateral malleoli fracture (3), superficial peroneal nerve injury (2), one early death, unrelated to the surgical procedure, delayed syndesmotic union (1), non-union (6) and deep infection (2), of which one underwent removal of the implant; the other receives long-term oral antibiotics. AOFAS scores improved from mean 40.4 pre-op to 83.5 post-op (p<0.001). Radiological assessment revealed 25 (93%) patients had lucency in at least one zone in the AP radiograph. We found a relatively high level of re-surgery and complications following Agility total ankle replacement. A 7% revision rate is much higher than would be tolerated in knee or hip arthroplasty, but compares favourably to other studies of TAR. Despite radiological loosening, and the high rate of re-surgery and complications; patients are generally satisfied with the procedure, reporting lower levels of pain and improved function. Overall, we feel that the Agility ankle is an acceptable alternative to arthrodesis, however patients should be warned of the risk of re-surgery

We aimed to review the outcome of Agility total ankle replacements carried out in our institution between 2002 and 2006. Follow-up consisted of clinical and radiological review pre-operatively, then at 6 weeks, 6 and 12 months, and annually until 10 years post op. Clinical review included the American Orthopaedic Foot and Ankle Score, satisfaction and pain scores. Case notes were reviewed to determine intra and post-operative complications. 30 arthroplasties were performed in 30 consecutive patients. Pre-operative diagnosis was rheumatoid arthritis(16), primary osteoarthritis(12) and post-traumatic osteoarthritis(2). After a mean follow up of 6.2 years (1.4–10.1), 4 patients had died, and 22 out of the remaining 24 were available for follow-up. Intra operative complications included lateral malleoli fracture(3) and superficial peroneal nerve injury(2). Post operative complications included 1 early death, but this was not related to the surgical procedure. Two patients developed deep infections of the prosthesis. One underwent removal of the implant; the other is on long term oral antibiotic therapy. One patient had delayed union of the syndesmosis and six patients had non-union. On clinical assessment, patients' AOFAS scores improved from mean 40.4 pre-op to 83.5 post-op (p<0.001). Radiological assessment of the tibial component revealed 25 (93%) patients had lucency in at least one zone in the AP radiograph. We found a relatively high level of re-surgery and complications following Agility total ankle replacement. A 7% revision rate is much higher than would be tolerated in knee or hip arthroplasty, but compares favourably to other studies of TAR. Despite radiological features which suggest loosening, the high rate of re-surgery and complications; patients are generally satisfied with the procedure, reporting lower levels of pain and improved function. Overall we feel that the Agility ankle is an acceptable alternative to ankle arthrodesis, however patients need to be warned of the risk of re-surgery

We aimed to review the outcome of Agility total ankle replacements carried out in our institution between 2002 and 2006. Follow-up consisted of clinical and radiological review pre-operatively, then at 6 weeks, 6 and 12 months, and annually until 10 years post op. Clinical review included the American Orthopaedic Foot and Ankle Score, satisfaction and pain scores. Case notes were reviewed to determine intra and post-operative complications. 30 arthroplasties were performed in 30 consecutive patients. Pre-operative diagnosis was rheumatoid arthritis(16), primary osteoarthritis(12) and post-traumatic osteoarthritis(2). After a mean follow up of 6.2 years (1.4–10.1), 4 patients had died, and 22 out of the remaining 24 were available for follow-up. Intra operative complications included lateral malleoli fracture(3) and superficial peroneal nerve injury(2). Post operative complications included 1 early death, but this was not related to the surgical procedure. Two patients developed deep infections of the prosthesis. One underwent removal of the implant; the other is on long term oral antibiotic therapy. One patient had delayed union of the syndesmosis and six patients had non-union. On clinical assessment, patients' AOFAS scores improved from mean 40.4 pre-op to 83.5 post-op (p< 0.001). Radiological assessment of the tibial component revealed 25 (93%) patients had lucency in at least one zone in the AP radiograph. We found a relatively high level of re-surgery and complications following Agility total ankle replacement. A 7% revision rate is much higher than would be tolerated in knee or hip arthroplasty, but compares favourably to other studies of TAR. Despite radiological features which suggest loosening, the high rate of re-surgery and complications; patients are generally satisfied with the procedure, reporting lower levels of pain and improved function. Overall we feel that the Agility ankle is an acceptable alternative to ankle arthrodesis, however patients need to be warned of the risk of re-surgery

1. Of fifty consecutive double hemiarthroplasties of the knee for rheumatoid arthritis using Maclntosh prostheses, forty-six were available for detailed assessment in thirty-six patients after one to six years. 2. Two early deaths were related to the operation but two late deaths were not. Three knees required revision, one of them twice. 3. The late results were 87 per cent good and 13 per cent fair. No patients followed up were the same as previously or worse. Every patient stated that he would have the operation performed again. 4. In our experience this operation in carefully selected patients produces satisfactory results. It is essential that great care is given to the operative technique

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

Complete fractures through bone affected by Paget's disease may not deserve their innocent reputation. This retrospective study of 182 such femoral fractures, the largest reported series to date, was carried out to discover the behaviour of these fractures in the absence of specific therapy for the Paget's disease. Most previous series have concluded that healing is uneventful but the findings in these patients from the West Midlands do not bear this out. After exclusion of the early deaths, the overall incidence of non-union was 40 per cent, the main problems being posed by the subtrochanteric fractures and those of the upper shaft. Although callus may be abundant, it may itself be involved in the disease process and is not a reliable sign of union. Based on these observations, suggestions for management in the different regions of the femur are made

1. Chronic tuberculous osseous lesions were induced consistently in eight- to ten-week-old unvaccinated guinea-pigs by the insertion of Gelfoam impregnated with mycobacterium tuberculosis into the metaphysial region through a drill hole in the distal part of the femur. Typical tuberculous lesions developed by three weeks and many of them were followed for twelve weeks or more. 2. This experimental model establishes a reliable method of producing a localised lesion at a predetermined site without early death of the animal. The model is sufficiently similar to the human lesion, and may offer a reliable system for further investigations. 3. It was observed that streptomycin penetrates readily into tuberculous osseous lesions. The concentration of streptomycin found in the tuberculous lesion after a single intramuscular injection was much higher than the concentration considered sufficient to have an inhibitory effect on the human type of mycobacterium tuberculosis

We have reviewed 41 patients with malignant extradural tumours of the spine treated by anterior decompression for cord compression, or uncontrolled back pain or both. An anterior operation alone was performed in 37 cases, four had combined or staged anterior and posterior decompression. An anterior operation on its own achieved major neurological recovery in 18 of the 33 cases with neurological loss (56%); only four remained unchanged. Eleven had minor improvement but not enough to allow them to walk or to regain bladder function. No patient with complete paraplegia gained a useful neurological recovery. Back pain was improved in 30 of the 41 patients (73%), sound internal fixation being important in this respect. There were four early deaths and another 23 died from disseminated disease after a mean survival of 4.1 months. Fourteen patients are still alive with a mean survival of 14 months

Aims: To elicit the predisposing factors responsible for early death in the aged population with hip fracture. Methods: In this perspective study we dealed with 65 patients over 65 years old (51 women) with mean age 80.1 years old (65 – 104) who suffered a hip fracture (34 trochanteric and 31 subcapital). We studied age, sex, ASA score, delay for surgery and mobility preoperatively, blood loss and operative time interoperatively and postoperative delirium and fixation failure. Haemoglobin, WBC, serum albumin and Mini Mental Test were recorded both pre and postoperatively. The place of the accident was also recorded. The above parameters were compared for survivors and non-survivors patients. Results: 11 patients died during the first 6 months with a mortality rate 16.9%. In all other parameters we detected no significant differences between groups. Conclusions: The failure pattern (deaths) after a hip fracture during the first 6 months postoperatively included female of advanced age, with dementia and medical problems (ASA), who developed delirium postoperatively and had diminished preoperatively mobility