Purpose: Comorbidities in patients undergoing total joint arthroplasty continue to be a challenging problem. Retrospective studies have demonstrated that co-morbidities affect outcomes of revision total knee arthroplasty (RTKA). However, the relationship between the outcomes of RTKA and co-morbidities has not been well established. This prospective randomized study was undertaken to investigate these relationships. Method: A prospective cohort study (the North America Knee Arthroplasty Revision Study) was conducted to examine factors that predict outcomes after RTKA. 308 subjects met inclusion/exclusion criteria. Subjects were followed from the time of the index surgery for a minimum of two years to monitor outcomes and complications. Validated quality of life instruments, including SF-36, WOMAC, Knee Society Score, and an activity scale were used. The rates of improvement from 0 to 12 and 12 to 24 months were analyzed. Results: There were 145 males and 163 females. The mean age was 68.7 years. Mean time from primary procedure to RTKA was 7.9 years. Arthroplasty failure was classified as aseptic in 82% and septic in 18% of the cases. Hypertension was seen in 62.4%, back pain in 50%, heart disease in 25.9%, diabetes mellitus in 23.9%, gastric ulcers in 17.9%, and rheumatoid arthritis in 16.6%. Less frequent co-morbidities included anemia, cancer, kidney disease, lung disease and liver disease. Conclusion: Analyses showed that the number of reported co-morbidities was the most significant predictor of outcomes, consistently forecasting poorer functional improvement on all measures. The results indicated that ultimate treatment of co-morbidities before and after surgery may improve outcomes of RTKA. Comorbidities in patients undergoing revision TKA can be a challenging problem. This study showed that the number of reported co-morbidities was the most significant predictor of poorer outcomes

Purpose: The comorbidities currently considered to increase surgical risk, particularly in the elderly, include heart disorders, diabetes, asthma, obesity, and chronic obstructive pulmonary disease (COPD). Further characterization of postoperative complications in relation to comorbidities is needed for lumbar decompression with fusion and instrumentation surgery. Methods: A chart review was conducted on the hospital and office records of 121 patients who underwent this procedure between the years of 2000 and 2003. Comorbidities were evaluated based on their tendency to cause related complications. The rate of wound infections was determined due to their relation to diabetes and obesity. Results: The age range was 65 to 89 years. Of 121 patients, 96 (79%) had comorbidities, and 12 (12.5%) of these had complications. There were 6 cardiac complications, 6 wound infections, and 2 diabetic challenges (1 patient experienced 3 complications). All 6 cardiac complication patients suffered from cardiac comorbidities. The wound infections presented in diabetics, obese patients, and cardiac disorder patients. Infections occurred in cardiac disorder patients only when diabetes and or obesity were present; 4 infected patients had this combination. Conclusions: The comorbidity and complication that presented with the highest correlation was heart disorders. There were no associated complications with pulmonary diseases. Surgeons should be increasingly aware of the wound infection threat to their cardiac disorder combined with obesity and or diabetic patients. The low rate of comorbid elderly patients who experienced postoperative complications gives statistical indication of safety for elderly patients to pursue complex lumbar surgery

Aims. The primary aim was to assess whether preoperative health-related quality of life (HRQoL) was associated with postoperative mortality following total hip arthroplasty (THA) and knee arthroplasty (KA). Secondary aims were to assess whether patient demographics/comorbidities and/or joint-specific function were associated with postoperative mortality. Methods. Patients undergoing THA (n = 717) and KA (n = 742) during a one-year period were identified retrospectively from an arthroplasty register. Patient demographics, comorbidities, Oxford score, and EuroQol five-dimension (EQ-5D) were recorded preoperatively. Patients were followed up for a minimum of seven years and their mortality status was obtained. Cox regression analysis was used to adjust for confounding. Results. During the study period, 111 patients (15.5%) undergoing THA and 135 patients (18.2%) undergoing KA had died at a mean follow-up of 7.5 years (7 to 8). When adjusting for confounding, the preoperative EQ-5D was associated with postoperative mortality, and for each 0.1 difference in the utility there was an associated change in mortality risk of 6.7% (p = 0.048) after THA, and 6.8% (p = 0.047) after KA. Comorbidities of connective tissue disease (p ≤ 0.026) and diabetes (p ≤ 0.028) were associated with mortality after THA, whereas MI (p ≤ 0.041), diabetes (p ≤ 0.009), and pain in other joints (p ≤ 0.050) were associated with mortality following KA. The preoperative Oxford score was associated with mortality, and for each one-point change in the score there was an associated change in mortality risk of 2.7% (p = 0.025) after THA and 4.3% (p = 0.003) after KA. Conclusion. Worse preoperative HRQoL and joint specific function were associated with an increased risk of postoperative mortality. Both HRQoL and joint-specific function decline with longer waiting times to surgery for THA and KA and therefore may result in an increased postoperative mortality risk than would have been expected if surgery had been undertaken earlier. Cite this article: Bone Jt Open 2022;3(12):933–940

Aims. Implant failure has become more common as the number of primary total ankle arthroplasties (TAAs) performed has increased. Although revision arthroplasty has gained attention for functional preservation, the long-term results remain unclear. This study aimed to assess the long-term outcomes of revision TAA using a mobile-bearing prosthesis in a considerably large cohort; the risk factors for failure were also determined. Methods. This single-centre retrospective cohort study included 116 patients (117 ankles) who underwent revision TAA for failed primary TAA between July 2000 and March 2010. Survival analysis and risk factor assessment were performed, and clinical performance and patient satisfaction were evaluated preoperatively and at last follow-up. Results. The mean duration from initial revision TAA to last follow-up was 15.0 years (SD 3.0; 11.2 to 20.5). The cumulative survival rates of the revised ankles were 81% (95% confidence interval (CI) 74% to 88%), 74% (65% to 82%), and 70% (61% to 79%) at five, ten, and 15 years, respectively. Comorbidities prior to primary TAA, aseptic loosening, instability, or grafting of cysts were found to be the most common risk factors for secondary revision. The median value for preoperative pain, as assessed using the visual analogue scale, declined from 6 (interquartile range (IQR) 5 to 8) to 2 (IQR 0 to 5) (p < 0.001) and the mean American Orthopaedic Foot and Ankle Society ankle-hindfoot score improved from 43 (SD 17) preoperatively to 70 (SD 20) (p < 0.001) at last follow-up. Conclusion. Revision TAA offers acceptable survival rates after 15 years; it therefore offers a valuable option for treatment of implant failure in carefully selected cases. Although patient-reported outcomes improve substantially, the degree of improvement reported following primary TAA is not achieved. Cite this article: Bone Joint J 2024;106-B(1):46–52

Background

There are advantages and disadvantages of Unicompartmental (UKR) and Total Knee Replacement, with UKR having better functional outcomes with fewer complications but a higher revision rate. The relative merits depend on patient characteristics. The aim was to compare UKR and TKR risk-benefits and cost-effectiveness in patients with severe systemic morbidity.

Abstract

Perthes’ disease is an osteonecrosis of the juvenile hip, the aetiology of which is unknown. A number of comorbid associations have been suggested that may offer insights into aetiology, yet the strength and validity of these are unclear. This study explored such associations through a case control study using the United Kingdom General Practice Research database. Associations investigated were those previously suggested within the literature. A total of 619 cases of Perthes’ disease were included, as were 2544 controls. The risk of Perthes’ disease was significantly increased with the presence of congenital anomalies of the genitourinary and inguinal region, such as hypospadias (odds ratio (OR) 4.04 (95% confidence interval (CI) 1.41 to 11.58)), undescended testis (OR 1.83 (95% CI 1.12 to 3.00)) and inguinal herniae (OR 1.79 (95% CI 1.02 to 3.16)). Attention deficit hyperactivity disorder was not associated with Perthes’ disease (OR 1.01 (95% CI 0.48 to 2.12)), although a generalised behavioural disorder was (OR 1.55 (95% CI 1.10 to 2.17)). Asthma significantly increased the risk of Perthes’ disease (OR 1.44 (95% CI 1.17 to 1.76)), which remained after adjusting for oral/parenteral steroid use.

Perthes’ disease has a significant association with congenital genitourinary and inguinal anomalies, suggesting that intra-uterine factors may be critical to causation. Other comorbid associations may offer insight to support or refute theories of pathogenesis.

An international Consensus Group has by a Delphi approach identified the topic of host factors affecting pin site infection to be one of the top 10 priorities in external fixator management. The aim of this study was to report the frequency of studies reporting on specific host factors as a significant association with pin site infection. Host factors to be assessed was: age, smoking, BMI and any comorbidity, diabetes, in particular. The intention was an ethological review, data was extracted if feasible, however no meta-analysis was performed.

A systematic literature search was performed according to the PRISMA-guidelines. The protocol was registered before data extraction in PROSPERO. The search string was based on the PICO criterias. A logic grid with key concept and index terms was made. A search string was built assisted by a librarian. The literature search was executed in three electronic bibliographic databases, including Embase MEDLINE (1111 hits) and CINAHL (2066 hits) via Ovid and Cochrane Library CENTRAL (387 hits). Inclusion criteria: external fixation, >1 pin site infection, host factor of interest, peer-reviewed journal. Exclusion criteria: Not written in English, German, Danish, Swedish, or Norwegian, animal or cadaveric studies, location on head, neck, spine, cranium or thorax, editorials or conference abstract. The screening process was done using Covidence.

A total of 3564 titles found. 3162 excluded by title and abstract screening. 140 assessed for full text eligibility. 11 studies included for data extraction. The included studies all had a retrospective design. Three identified as case-control studies. Generally the included studies was assessed to have a high risk of bias. A significant associations between pin site infection for following host factors: a) increased HbA1C level in diabetic patients; b) congestive heart failure in diabetic patients; c) less co-morbidity; d) preoperative osteomyelitis was found individually.

This systematic literature search identified a surprisingly low number of studies examining for risk of pin site infection and host factors. Thus, this review most of all serves to demonstrate a gap of evidence about correlation between host factors and risk of pin site infection, and further studies are warranted.

Charlson Index has been found to predict functional outcome, implant survival, mortality, length of hospital stay and resource use after arthroplasty. Obesity can influence the outcome following lower limb arthroplasty. Our aim was to identify if there was a relationship between Charlson index, obesity and disability and whether this relationship had altered in recent years.

Demographic details, Charlson index, BMI, SF-12 and oxford score were recorded prospectively for 88 consecutive patients undergoing lower limb arthroplasty between August 2011 and January 2012(Group B). The results were compared with Charlson index of 92 consecutive patients between August 2005 and March 2006(Group A).

The mean age for Group A was 70 years (range 41–90). 56(61%) were female and 36(39%) male. The mean Carlson index was 3 (range 0–6) and median was 3. The mean age for Group B was 67 years (range 45–91). 53(60%) were female and 35(40%) male. The mean Charlson index was 2.2 (range 0–11) and median was 0. The difference between the groups was statistically significant with a P value of 0.001. The mean BMI for Group B was 31 (range 15–56) and median 30. Thirteen patients (15%) had BMI<25, 29 patients (33%) had BMI between 25–29. 9(Pre-Obese), 23 patients (26%) had BMI between 30–34. 9(Obese-Class 1), 10 patients (11%) had BMI between 35–39. 9(Obese-Class 2)and 13 patients (15%) had BMI>40 (Obese-Class 3). The only difference between group B1(BMI<30) and B2(BMI>30) was of age with a P value of 0.0003 (72 vs 59 years).

The current group had less comorbidity but 85% of patients were overweight or obese. These patients were younger but there was no difference in their health or disability before surgery. The high prevalence of obesity may represent treatment selection of these patients away from waiting list centres. Consideration about the treatment of obesity should be given before lower limb arthroplasty.

Background

The ability to identify those at risk for longer inpatient stay helps providers with postoperative planning and patient expectations. Decreasing length of stay in the future will be determined by appropriate patient selection, risk stratification, and pre-operative patient optimization. The purpose of this study was to identify factors that place patients at risk for extended postoperative lengths of stay.

Introduction

Fracture around the knee can lead to posttraumatic osteoarthritis (PTOA) of the knee. Malunion, malalignment, intra-articular osseous defects, retained internal fixation devices, and compromised soft tissues may affect the outcome of total knee replacement (TKR). On average, the posttraumatic patient subsets were 10.4 years younger than those for primary knee OA. Recently, there were several studies reporting the outcome of THA for posttraumatic OA hip. However, no current literature defines the comparative functional outcome between PTOA and primary OA knee.

The purpose of our study was to compare the midterm outcomes of patients undergoing TKR following periarticular knee fractures/ligamentous injuries versus primary osteoarthritis (PO) of the knee.

Preoperative antibiotic prophylaxis remains one of the most important strategies for preventing periprosthetic joint infection (PJI). Current guidelines recommend giving universal antibiotic prophylaxis to all total joint arthroplasty (TJA) patients regardless of their medical conditions or immune status. The aims of this study were to determine if comorbidities influence the organism profile of PJIs and to investigate if the efficacy of the two most frequently used perioperative antibiotics (cefazolin or vancomycin) are affected by patient comorbidities.

Using an institutional database, the influence of comorbidities on the organism profile of 1022 PJIs was evaluated. To investigate the influence of perioperative antibiotic monotherapy (cefazolin or vancomycin therapy) on PJI, 8575 primary TJAs were identified and analyzed based on their comorbidities. Patients with multiple perioperative antibiotics, prior septic arthritis, unavailable perioperative antibiotic information, or who underwent aseptic revision were excluded. PJI was determined from ICD-9 codes.

While no comorbidities were associated with an increased rate of gram-positive or gram-negative infections, metastatic disease (odds ratio [OR] 7.54, p=0.006), rheumatologic disease (OR 1.63, p=0.046), and chronic pulmonary disease (OR 1.46, p=0.030) demonstrated an increased risk of Staphylococcus aureus PJI. In addition, metastatic disease (OR 5.71, 95% confidence interval [CI] 1.12–26.93, p=0.018), congestive heart failure (OR 2.2, 95% CI 1.16–4.00, p=0.010), chronic pulmonary disease (OR 1.76; 95% CI 1.09–2.78, p=0.015), and diabetes (OR 1.66; 95% CI 1.08–2.52, p=0.019) were associated with PJI from antibiotic resistant organisms. However, there was no difference in the rate of PJI between cefazolin and vancomycin monotherapy when stratified for the aforementioned comorbidities.

The present study reveals that comorbidities do not significantly alter the organism profile of high-risk comorbidities and that comorbidities associated with immune deficits do not influence the rate of PJI between two different antibiotics. The results of this study thus support current guidelines, which provide a universal recommendation rather than a protocol that is tailored to a patient's preexisting comorbidities.

Aims

For the increasing number of working-age patients undergoing total hip or total knee arthroplasty (THA/TKA), return to work (RTW) after surgery is crucial. We investigated the association between occupational class and time to RTW after THA or TKA.

Aims

Achilles tendon re-rupture (ATRR) poses a significant risk of postoperative complication, even after a successful initial surgical repair. This study aimed to identify risk factors associated with Achilles tendon re-rupture following operative fixation.

Aims

Proximal femur fractures treatment can involve anterograde nailing with a single or double cephalic screw. An undesirable failure for this fixation is screw cut-out. In a single-screw nail, a tip-apex distance (TAD) greater than 25 mm has been associated with an increased risk of cut-out. The aim of the study was to examine the role of TAD as a risk factor in a cephalic double-screw nail.

Aims

Patients with femoral neck fractures (FNFs) treated with total hip arthroplasty (THA) have an almost ten-fold increased risk of dislocation compared to patients undergoing elective THA. The surgical approach influences the risk of dislocation. To date, the influence of differing head sizes and dual-mobility components (DMCs) on the risk of dislocation has not been well studied.

Aims

In countries with social healthcare systems, such as Canada, patients may experience long wait times and a decline in their health status prior to their operation. The aim of this study is to explore the association between long preoperative wait times (WT) and acute hospital length of stay (LoS) for primary arthroplasty of the knee and hip.

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.

Aims

Patients with a high comorbidity burden (HCB) can achieve similar improvements in quality of life compared with low-risk patients, but greater morbidity may deter surgeons from operating on these patients. Whether surgeon volume influences total hip arthroplasty (THA) outcomes in HCB patients has not been investigated. This study aimed to compare complication rates and implant survivorship in HCB patients operated on by high-volume (HV) and non-HV THA surgeons.

Aims

To investigate the impact of the Charlson and Elixhauser comorbidity indices on patient-reported outcomes measures (PROMs) following shoulder arthroplasty.

Aims

The aim of this study was to examine whether socioeconomic status (SES) is associated with a higher risk of infections following total hip arthroplasty (THA) at 30 and 90 days.

Aims

The success of total knee arthroplasty (TKA) is usually measured using functional outcome scores and revision-free survivorship. However, reporting the lifetime risk of revision may be more meaningful to patients when gauging risks, especially in younger patients. We aimed to assess the lifetime risk of revision for patients in different age categories at the time of undergoing primary TKA.

Aims

The aim of this study is to define a core outcome set (COS) to allow consistency in outcome reporting amongst studies investigating the management of orthopaedic treatment in children with spinal dysraphism (SD).

Aims. Social determinants of health (SDOHs) may contribute to the total cost of care (TCOC) for patients undergoing total knee arthroplasty (TKA). The aim of this study was to investigate the association between demographic data, health status, and SDOHs on 30-day length of stay (LOS) and TCOC after this procedure. Methods. Patients who underwent TKA between 1 January 2018 and 31 December 2019 were identified. A total of 234 patients with complete SDOH data were included. Data were drawn from the Chesapeake Regional Information System, the Centers for Disease Control social vulnerability index (SVI), the US Department of Agriculture, and institutional electronic medical records. The SVI identifies areas vulnerable to catastrophic events with four themed scores: socioeconomic status; household composition and disability; minority status and language; and housing and transportation. Food deserts were defined as neighbourhoods located one or ten miles from a grocery store in urban and rural areas, respectively. Multiple regression analyses were performed to determine associations with LOS and costs after controlling for various demographic parameters. Results. Divorced status was significantly associated with an increased LOS (p = 0.043). Comorbidities significantly associated with an increased LOS included chronic obstructive pulmonary disease/asthma and congestive heart failure (p = 0.043 and p = 0.001, respectively). Communities with a higher density of tobacco stores were significantly associated with an increased LOS (p = 0.017). Comorbidities significantly associated with an increased TCOC included chronic obstructive pulmonary disease (p = 0.004), dementia (p = 0.048), and heart failure (p = 0.007). Increased TCOCs were significantly associated with patients who lived in food deserts (p = 0.001) and in areas with an increased density of tobacco stores (p = 0.023). Conclusion. Divorced marital status was significantly associated with an increased LOS following TKA. Living in food deserts and in communities with more tobacco stores were significant risk factors for increased LOS and TCOC. Food access and ease of acquiring tobacco may both prove to be prognostic of outcome after TKA and an opportunity for intervention. Cite this article: Bone Joint J 2021;103-B(6 Supple A):113–118

Infections in spine surgery are relatively common and devastating complications, a significant burden to the patient and the healthcare system. Usually, the treatment of SSIs consists of aggressive and prolonged antibiotic therapy, multiple debridements, and in chronic cases, hardware removal. Infections are correlated with worse subjective outcomes and even higher mortality. Depending on the type of spine surgery, the infection rate has been reported to be as higher as 20%. Recently silver-coated implants have been introduced in spine surgery to reduce the incidence of post-operative infections and to improve implant survivorship. The aim of the present study is to evaluate complications and outcomes in patients treated with silver-coated implants because of spine infection. All consecutive patients who had spine stabilization with a silver-coated implant from 2018 to 2021 were screened for inclusion in the study. Inclusion criteria were: (1) six months of minimum follow-up; (2) previous surgical site infection; hematogenous spondylodiscitis requiring surgical stabilization. Demographic and surgical information were obtained via chart review, all the device-related complications and the reoperation rate were also reported. A total of 57 patients were included in the present study. The mean age was 63.4 years, and there were 36 (63%) males and 21 (37%) females. Among the included cases, 57% were SSIs, 33% were spondylodiscitis, and 9% were hardware mobilization. Comorbidities such as diabetes mellitus, obesity, smoke, and oncological history were significant risk factors. In addition, the organisms cultured were Staphylococcus species in most of the cases. At six months of follow-up, 40% of patients were considered free from infection, while 20% needed multiple surgeries. The present research showed satisfactory results of silver-coated implants for the treatment of spine infection

Adverse events (AEs) are still a major problem in spinal surgery, despite advances in surgical techniques, innovative technologies available and the introduction of checklist and predictive score systems aimed at reducing surgical complications. We previously analysed the results of the introduction of the WHO Safety Surgical Checklist (SSC) in our Institution, comparing the incidence of complications between two periods: from January to December 2010 (without checklist) and from January 2011 and December 2012 (with checklist), in order to assess the checklist effectiveness. The sample size was 917 patients with an average of 30 months of follow-up. Complications were observed in 107 patients (11.6%) among 917 spinal surgery procedures performed, with 159 (17.3%) complications in total. The overall incidence of complications for trauma, infectious pathology, oncology, and degenerative disease was 22.2%, 19.2%, 18.4%, and 15.3%, respectively. We observed a reduction of the overall incidence of complications following the introduction of the WHO Surgical Checklist: in 2010 without checklist, the incidence of complications was 24.2%, while in 2011 and 2012, following the checklist introduction, the incidence of complications was 16.7% and 11.7%, respectively (mean 14.2%) (p<0.0005). Thus, the SSC appeared to be an effective tool to reduce complications in spinal surgery and we proposed to extend the use of checklist system also to the pre-operative and post-operative phases in order to further reduce the incidence of complications. We also believe that a correct capture and classification of complications is fundamental to generate a clinical decision support system aimed at improving patients’ safety in spinal surgery. In the period between January 2017 and January 2018 we prospectively recorded the adverse events and complications of patients undergoing spinal surgery in our department, without using any collection system. Then we retrospectively recorded the intraoperative and postoperative adverse events of surgically treated patients during the same one-year period, using the SAVES v2 system introduced by Rampersaud and collaborators (Rampersaud YR et al. J Neurosurg Spine 2016 Aug; 25 (2): 256-63) to classify them. In the one-year period from January 2017 to January 2018 a total of 336 patients underwent spinal surgery: 223 for degenerative conditions and 113 for spinal tumors. Comorbidities were collected (Charlson Comorbidity Index [CCI]). Overall, a higher number of adverse events (AEs) was recorded using SAVES compared to the prospective recording without the use of any capture system and the increased number was statistically significant for early postoperative AEs (138/336 vs 44/336, p<0.001). 210 adverse events were retrospectively recorded using the SAVES system (30 intraoperative adverse events, 138 early postoperative and 42 late postoperative adverse events). 99 patients (29.5%) on the cohort had at least one complication. Furthermore, the correlation between some risk factors and the onset of complications or the prolonged length of stay was statistically analyzed. The risk factors taken into account were: age, presence of comorbidities (CCI), ASA score, previous surgery at the same level, type of intervention, location of the disease, duration of the surgery. In particular, the duration of the surgery (more than 3 hours) and the presence of previous surgeries resulted to be risk factors for complications in multivariate analyses

Aims. Access to joint replacement is being restricted for patients with comorbidities in a number of high-income countries. However, there is little evidence on the impact of comorbidities on outcomes. The purpose of this study was to determine the safety and effectiveness of hip and knee arthroplasty in patients with and without comorbidities. Methods. In total, 312,079 hip arthroplasty and 328,753 knee arthroplasty patients were included. A total of 11 common comorbidities were identified in administrative hospital records. Safety risks were measured by assessing length of hospital stay (LOS) and 30-day emergency readmissions and mortality. Effectiveness outcomes were changes in Oxford Hip or Knee Scores (OHS/OKS) (scale from 0 (worst) to 48 (best)) and in health-related quality of life (EQ-5D) (scale from 0 (death) to 1 (full health)) from immediately before, to six months after, surgery. Regression analysis was used to estimate adjusted mean differences (LOS, change in OHS/OKS/EQ-5D) and risk differences (readmissions and mortality). Results. Patients with comorbidities had a longer LOS and higher readmission and mortality rates than patients without. In hip arthroplasty patients with heart disease, for example, LOS was 1.20 days (95% confidence interval (CI) 1.15 to 1.25) longer and readmission rate was 1.52% (95% CI 1.34% to 1.71%) and mortality 0.19% (95% CI 0.15% to 0.23%) higher. Similar patterns were observed for knee arthroplasty patients. Patients without comorbidities reported large improvements in function (mean improvement OHS 21.3 (SD 9.91) and OKS 15.9 (SD 10.0)). Patients with comorbidities reported only slightly smaller improvements. In patients with heart disease, mean improvement in OHS was 0.39 (95% CI 0.27 to 0.51) and in OKS 0.56 (95% CI 0.45 to 0.67) less than in patients without comorbidities. There were no significant differences in EQ-5D improvement. Conclusion. Comorbidities were associated with small increases in adverse safety risks but they have little impact on pain or function in patients undergoing hip or knee arthroplasty. These results do not support restricting access to hip and knee arthroplasty for patients with common comorbidities. Cite this article: Bone Joint J 2021;103-B(1):56–64

Necrotizing Fasciitis (NF) is a life-threatening infectious condition which requires expedient diagnosis to proceed with urgent surgical debridement. However, it can be difficult to establish an early diagnosis and expedite operative management as signs and symptoms are often non-specific and may mimic other pathology. Scoring systems such as The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) have been proposed to incorporate laboratory findings to predict whether a soft tissue infection is likely to be NF. Recent studies have found the sensitivity and specificity of the LRINEC tool to be lower than originally cited by the LRINEC authors in a validation cohort. Furthermore, there seems to be a predilection for certain geographic locations of patients with NF transferred to our tertiary care center for management, however, to our knowledge, geographic risk factors for NF have not been reported. This study also aims to determine the morbidity and mortality rate of NF at our Canadian tertiary hospital in recent years. Comorbidities such as smoking, diabetes, and steroid use will be analyzed for any correlation with developing NF. Identification of patient factors in correlation with laboratory values may help identify patients at higher risk for having NF upon their presentation to the emergency department. A resultant earlier diagnosis of necrotizing soft tissue infections would allow for earlier surgical debridement and positively influence patient outcomes. A retrospective chart review of 125 cases of NF at Kingston Health Sciences Centre from 2005 to 2017 was carried out to assess the validity of the LRINEC in our population and to examine the effect of comorbid factors such as smoking, diabetes, and corticosteroid use on the development of NF. The study cohort included patients treated by all surgical disciplines at our institution over twelve years. A separate cohort of 125 cellulitis or abscess cases was analyzed to assess the validity of the LRINEC tool in differentiating necrotizing fasciitis from non-necrotizing infections such as cellulitis and soft tissue abscess. The 30-day mortality rate of NF treated at our institution during the study period was 21%. Advanced age was found to be a significant risk factor for death within 30 days of diagnosis (p=0.001). Smoking and steroid use were both found to increase risk for developing NF (p=0.01 and p=0.03, respectively). Diabetes did not appear to increase risk NF. There was no statistical difference in mortality rates between males and females with NF. The sensitivity of LRINEC in detecting NF was only 47% with a specificity of 74%. The mortality rate of NF at our center is similar to that of other countries in recent years. Males and females have nearly equal mortality rates from NF. Smoking and steroid use appear to increase risk for developing NF, while diabetes may not. The LRINEC assessment tool alone may underestimate risk for developing NF, however, use of other clinical factors such as comorbidity analysis will further aide in the diagnosis of NF allowing for earlier surgical debridement

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

Introduction. Total knee arthroplasty is very successful although the clinical assessment and rated outcome does not always match the patients reported satisfaction. One reason for patient dissatisfaction is less than desired range of motion. Poor postoperative motion inhibits many functional activities and may create a perception of dysfunction. Early in the postoperative period when patients are having trouble regaining motion (usually 6–8 weeks), manipulation under anesthesia can be used to advance range of motion by manually lysing adhesions. Comorbidities have been used as predictors for outcome in total knee arthroplasty in population health studies. Likewise, predicting which patients are most susceptible to early postoperative stiffness/manipulation would be valuable for patient education and to predict outcome. Methods. Prospectively collected data was retrieved from the hospital's MARCQI database (Michigan Arthroplasty Collaborative Quality Initiative) for the years 2014–2018. There were 3098 primary total knees performed during the study period and 139 manipulations (4.44%). The registry specifically abstracts patients’ preoperative comorbidities, operative data, and 90-day postoperative complications. Results. There were 2118 Cruciate Retaining/Cruciate Stabilized knees (105 MUA), 801 Posterior Stabilized (33), and 41 Total Stabilized/Hinge (1), 2160 knees were cemented (91) and 799 uncemented (48). No differences were found between the manipulation and non-manipulation groups for gender, race, alcohol consumption, bleeding disorders, history of DVT or PE, Diabetes, or use of pre-op narcotics or anti-coagulents. Patients undergoing manipulation were younger (67.2 vs. 63.8, p= 0.00001), had a lower BMI (32.6 vs. 30.9 p= 0.0007), and were more likely to be non or former (quit) smokers. There were no differences noted for the constraint of the component (cr/ps), or whether the implants were cemented or uncemented (35% vs. 27%, p= 0.064). Conclusions. Understanding the risk for postoperative stiffness and the potential for manipulation is helpful in the preoperative period for patient education and outcome prediction. Assessing comorbidities and patient characteristics may help avoid the need for manipulations postoperatively. This patient cohort may be biased since the manipulations were not based on predetermined criteria. The cohort represents patients whose range of motion was poor enough to cause the surgeon to perform the procedure. The findings do however highlight a patient pool that was surprisingly at risk: younger, thinner, nonsmokers regardless the implant design or use of cement

Aims. The aim of the study was to analyze the results of primary tendon reinsertion in acute and chronic distal triceps tendon ruptures (DTTRs) in the general population. Patients and Methods. A total of 28 patients were operated on for primary DTTR reinsertions, including 21 male patients and seven female patients with a mean age of 45 years (14 to 76). Of these patients, 23 sustained an acute DTTR and five had a chronic injury. One patient had a non-simultaneous bilateral DTTR. Seven patients had DTTR-associated ipsilateral fracture or dislocation. Comorbidities were present in four patients. Surgical treatment included transosseous and suture-anchors reinsertion in 22 and seven DTTRs, respectively. The clinical evaluation was performed using Mayo Elbow Performance Score (MEPS), the modified American Shoulder and Elbow Surgeons Score (m-ASES), the Quick Disabilities of the Arm, Shoulder and Hand score (QuickDASH), and the Medical Research Council (MRC) Scale. Results. A total of 27 patients (28 DTTRs) were available for review at a mean of 47.5 months (12 to 204). The mean MEPS, QuickDASH, and m-ASES scores were 94 (60 to 100), 10 (0 to 52), and 94 (58 to 100), respectively. Satisfactory results were observed in 26 cases (93%). Muscle strength was 5/5 and 4/5 in 18 and ten DTTRs, respectively. One patient with chronic renal failure experienced a traumatic rerupture of distal triceps. One patient (1 DTTR) experienced mild elbow stiffness. Conclusion. Primary repair of acute and chronic DTTRs in a general population yields satisfactory results in the majority of patients with a low rerupture rate. Cite this article: Bone Joint J 2018;100-B:610–16

Introduction. Bundle payment models have clinical and economic impacts on providers. Despite efforts made to improve care, experience has shown that a few episodes with costs well above a target (bundle busters) can reduce or negate positive performances. The purpose of this study was to identify both the primary episode drivers of cost and patient factors that led to episodes above target. Methods. A retrospective study of 10,000 joint replacement episodes from a large healthcare system in CJR and a private orthopedic practice in BPCI was conducted. Episodes with costs greater than target price (TP) were designated as bundle busters and sub-divided into 4 groups:. 1). < 1 standard deviation (SD) above TP (n=1700). 2). > 1 to 2 SD above TP (n=240). 3). > 2 to 3 SD above TP (n=70). 4). > 3 SD above TP (n=70). Bundle busters were compared to the control that were at/below the TP (n= 7500). For the CJR/BPCI cohorts, one SD was defined as $10,700/$13,000, respectively. Two linear regressions assessed the likelihood of factors predicting a bundle buster and the total episode cost. These variables included demographics, acuity classifications, comorbidities, length of stay, readmissions, discharge disposition, post-acute utilization, and episode costs. Results. Group 1 had 66% higher total episode costs than the control group, 13% higher hospital costs, and 144% higher SNF costs. Costs for Group 2 were at least double that of Group 1. Significant predictors for bundle busters included, race, age, comorbidities, BMI, and LOS. (P<0.01) Significant predictors for total episode costs included, gender, age, ROM, SOI, comorbidities, and BMI. (P<0.1). Discussion. Age, Comorbidities, and BMI are among significant predictors of higher total episode costs. Identifying drivers and factors that impact bundle busters supports the importance of care model improvements that mitigate risks associated with these patients

Aim. There is a theoretical advantage for immediate postoperative start of rifampicin after debridement, antibiotics and implant retention (DAIR). Anti-biofilm treatment may be mostly needed during the first postoperative days in order to prevent new biofilm formation. However, there are concerns with regard to development of rifampicin resistance if rifampicin is started too early. Rifampicin monotherapy will rapidly result in rifampicin resistance, but this may not occur when prescribed as part of combination antimicrobial therapy and after thorough surgical debridement. We hypothesized that in this setting the probability of development of rifampicin resistance is very low. We evaluated the frequency of development of rifampicin resistance in patients with acute staphylococcal PJI who were treated with DAIR followed by immediate postoperative start of rifampicin in combination with a betalactam or glycopeptide. Method. During 2003–2014, all patients with an acute staphylococcal PJI were treated with five days of high-dose rifampicin (600mg bid) in combination with at least 6 weeks of betalactam or glycopeptide antibiotics, both started immediately postoperative after DAIR. Clinical outcome and development of rifampicin resistance in patients who failed were monitored. Susceptibility testing for rifampicin was performed by Vitek 2 (Biomerieux). Until 2014, Clinical and Laboratory Standards Institute (CLSI) criteria for rifampicin resistance were applied (S ≤ 1), from 2014 EUCAST criteria (S ≤ 0.06) were applied. Results. Forty-one patients with acute staphylococcal hip (22) of knee (19) PJI were included. Comorbidities were rheumatoid arthritis (22%), diabetes (10%), a tumor prosthesis due to malignancy (34%) and corticosteroid use (27%). Fifteen patients (37%) developed a failure after DAIR. Eight failures were caused by the same staphylococcal species as the initial PJI (six Staphylococcus aureus, two Coagulase-negative staphylococci). In all failures, rifampicin susceptibility of the isolate had not changed. One patient was started on chronic suppressive treatment (not including rifampicin) and had a prosthetic joint removal 18 months later. In this patient, one out of five positive cultures with S. aureus from the removed prosthesis showed a rifampicin resistant strain. In all failures, mean duration between the initial DAIR and failure was 208 days (range 7–636 days). Conclusions. Immediate postoperative start of high-dose rifampicin in combination with betalactam or glycopeptide did not result in rifampicin resistant staphylococci among patient who had a failure with the same staphylococci. These results strongly indicate that immediate postoperative start of rifampicin is safe. Larger studies are needed to prove the clinical benefit of this strategy

Aim. Bone and joint infections (BJI) are associated with a heavy morbidity and high health costs. Comorbidities, device associated infections and complicated journeys are associated with increased mortality, treatment failures and costs. For this reason, 24 referral centers (RC) have been created in 2009 in order to advise about management of “complex” BJI in weekly multidisciplinary meetings (MM). Since end of 2012, data from these meetings are gathered in a national database. We aimed to describe the data from this French registry of BJI and determine factors associated with the definition of “complex” BJI. Method. Demographic, clinical, microbiologic and therapeutic characteristics of patients are systematically recorded in the database. Data from the first presentation in RC for each adult patients are presented. Complexity of BJI is recorded after each meeting according to 4 criteria (first failure, complex antibiotic therapy, precarious underlying conditions or complex surgical procedure). Part of unavailable data have been completed by pattern extraction from text-encoded commentaries. Factors associated with complexity were determined by multivariate logistic regression. Results. From 2012 to 2016, 17.527 patients were included corresponding to 30.300 presentations in MM. Median age was 64 years (IQR 50–76) with masculine predominance (61.8%). Comorbidity was present in 50.3%, with at least 2 comorbidities in 26%. Prosthetic joint infection represented 41.4% of patients, followed by chronic osteitis with/without foreign material (24%). Definite microbiologic documentation was available in 68.8% of cases, mostly Staphylococcus aureus (43.9%) followed by Coagulase negative Staphylococci (28.6%) and enterobacteriaceae (23.1%), with 27.4% of polybacterial infections. Antibiotic treatment was proposed in 81.6% and surgery in 70% of cases. BJI were defined as complex in 55.4%, mostly because underlying conditions (50%), and in 57.6% with at least 2 complexity criteria. Factors positively associated with definition of complexity in MM were: background: number of comorbidities, immunodeficiency, neoplasia, liver or kidney failure, intra-cardiac device; microbiology: Mycobacteria, Fungus, MRSA, MSSA, MR-CoNS, MDR enterobacteria, non-fermentative BGN, and atypical pathogens (actinomycetes, nocardia, intra-cellular …); infection characteristics: prosthetic joint infection, osteitis, foreign material infection, arthritis and number of infected sites; surgical procedures: surgical flap, 2 stages prosthesis exchange, spacer, arthrodesis, and joint removal. Simple debridement was negatively associated with complex definition. Conclusions. This registry is the first national prospective database about management of BJI in France and provide many information about epidemiology and management of BJI in France, as well as a more precise definition of complexity

Background. Readmission following any total joint arthroplasty has become a closely watched metric for many hospitals in the United States because financial penalties imposed by CMS for excessive readmissions occurring within thirty days of discharge has occurred since 2015. The purpose of this study was to identify both preoperative comorbidities associated with and postoperative reasons for readmission within thirty days following primary total joint arthroplasty in the lower extremity. Methods. Retrospective data was collected for patients who underwent elective primary total hip arthroplasty (CPT code 27130), total knee arthroplasty (27447), and total ankle arthroplasty (27702) from January 1, 2008, to December 31, 2013 at our institution. The sample was separated into readmitted and non-readmitted cohorts. Demographic variables, preoperative comorbidities, Charlson Comorbidities Index (CCI), operative parameters, readmission rates, and causes of readmission were compared between the groups using univariate and multivariate regression analysis. Results. There were 42 (3.4%), 28 (2.2%), and 1 (0.5%) readmissions within 30 days for THA, TKA, and TAA, respectively. The most common cause of readmission within 30 days following total joint arthroplasty in lower extremity was infection. Trauma was the second most common reason for readmission of a THA while wound dehiscence was the second most common cause for readmission following TKA. With univariate regression, there were multiple associated factors for readmission among total hip and total knee arthroplasty patients including BMI, metabolic equivalent (MET), and CCI. Multivariate regression revealed that hospital length of stay was significantly associated with 30-day readmission after THA and TKA. Conclusion. Patient co-morbidities and pre-operative functional capacity significantly affect 30-day readmission rate following total joint arthroplasty. Adjustments for these parameters should be considered when hospital penalties are calculated with regard to 30-day readmission. Level of Evidence. Level III; Retrospective cohort study

Background. Inpatient dislocation after total hip arthroplasty (THA) is considered a non-reimbursable “never event” by the Centers for Medicare and Medicaid Services. There is extensive evidence that technical procedural factors affect dislocation risk, but less is known about the influence of non-technical factors. We evaluated inpatient dislocation trends following elective primary THA, and identified patient and hospital characteristics associated with the occurrence of dislocation. Methods. We used discharge records from the Nationwide Inpatient Sample (2002–2011). Temporal trends were assessed and multivariable logistic regression modeling was used to identify factors associated with dislocation. Results. The in-hospital dislocation rate increased from 0.025% in 2002 to 0.15% in 2011, despite a downward trend in length of stay (P<0.001). Patient characteristics associated with the occurrence of dislocation were black or Hispanic race/ethnicity, lower household income, and Medicaid insurance. Comorbidities associated with dislocation included hemiparesis/hemiplegia, drug use disorder, chronic renal failure, psychosis, and obesity. Dislocations were less likely to occur at teaching hospitals and in the South. Conclusion. The in-hospital dislocation rate following elective primary THA is increasing, in spite of shorter stays and surgical advances over time. Given the sociodemographic disparities in dislocation risk documented herein, interventions to address social determinants of health might do as much or more to reduce the occurrence of dislocation than technical improvements

Background. Outcomes for patients with acute illnesses may be affected by the day of the week they present to hospital. Policy makers state this ‘weekend effect’ to be the main reason for pursuing a change in consultant weekend working patterns. However, it is uncertain whether such a phenomenon exists for elective orthopaedic surgery. This study investigated whether a ‘weekend effect’ contributed to adverse outcomes in patients undergoing elective hip and knee replacements. Methods. Retrospectively collected data was obtained from our institutions electronic patient records. Using univariate analysis, we examined potential risk factors including; Age, Sex, ASA Grade, Comorbidities, as well as the day of the week surgery was undertaken. Subsequent multivariate analyses identified covariate-adjusted risk factors, associated with prolonged hospital stays. 30-day mortality data was assessed according to the day of the week surgery was performed. Results. 892 patients underwent arthroplasty surgery from 01/09/2014 till the 31/08/2015. 457 had a total hip and 435 had a total knee replacement. 814 patients (91.3%) underwent surgery during the week, while 78 patients (8.7%) had surgery on a Saturday. There was no difference in the average Length of Stay (LOS) between groups (5.0, 2.6 versus 5.0, 3.4, p=0.95), and weekend surgery was not associated with a LOS greater than 4 days. The two variables found to be associated with a prolonged LOS were; increasing age (RR) 1.02 (95% CI: 1.01–1.03, p<0.001) and an ASA score of 2, (RR) 1.6 (95% CI: 1.15– 2.20, p=0.005). There was one death in a patient who was ASA III, and who underwent surgery on a Monday. Conclusion. There is no ‘weekend effect’ for elective orthopaedic surgery. Changes in consultant weekend working patterns are unlikely to have any effect on mortality or LOS for elective orthopaedic patients

Background. Readmission following any total joint arthroplasty has become a closely watched metric for many hospitals in the United States because financial penalties imposed by CMS for excessive readmissions occurring within thirty days of discharge will be forthcoming in 2015. The purpose of this study was to identify both preoperative comorbidities associated with and postoperative reasons for readmission within thirty days following primary total joint arthroplasty in the lower extremity. Methods. Retrospective data was collected for patients who underwent elective primary total hip arthroplasty (CPT code 27130), total knee arthroplasty (27447), and total ankle arthroplasty (27702) from January 1, 2008, to December 31, 2013 at our institution. The sample was separated into readmitted and non-readmitted cohorts. Demographic variables, preoperative comorbidities, Charlson Comorbidities Index (CCI), operative parameters, readmission rates, and causes of readmission were compared between the groups using univariate and multivariate regression analysis. Results. There were 42 (3.4%), 28 (2.2%), and 1 (0.5%) readmissions within 30 days for THA, TKA, and TAA, respectively. The most common cause of readmission within 30 days following total joint arthroplasty in lower extremity was infection. Trauma was the second most common reason for readmission of a THA while wound dehiscence was the second most common cause for readmission following TKA. With univariate regression, there were multiple associated factors for readmission among total hip and total knee arthroplasty patients including BMI, metabolic equivalent (MET), and CCI. Multivariate regression revealed that hospital length of stay was significantly associated with 30-day readmission after THA and TKA. Conclusion. Patient co-morbidities and pre-operative functional capacity significantly affect 30-day readmission rate following total joint arthroplasty. Adjustments for these parameters should be considered when hospital penalties are calculated with regard to 30-day readmission

Outcomes for patients with acute illnesses may be affected by the day of the week they present to hospital. Policy makers state this ‘weekend effect’ to be the main reason for pursuing a change in consultant weekend working patterns. However, it is uncertain whether such a phenomenon exists for elective orthopaedic surgery. This study investigated whether a ‘weekend effect’ contributed to adverse outcomes in patients undergoing elective hip and knee replacements. Retrospectively collected data was obtained from our institutions electronic patient records. Using univariate analysis, we examined potential risk factors including; Age, Sex, ASA Grade, Comorbidities, as well as the day of the week, hospital admission and surgery occurred. Subsequent multivariate analyses identified covariate- adjusted risk factors, associated with prolonged hospital stays. 30-day mortality data was assessed according to the day of the week surgery was performed. 892 patients underwent arthroplasty surgery from 01/09/2014 till the 31/08/2015. 457 patients had a total hip and 435 had a total knee replacement. 814 patients (91.3%) underwent surgery during the week, while 78 (8.7%) had surgery on a Saturday. There was no difference in the average Length of Stay (LOS) between groups (5.0, 2.6 versus 5.0, 3.4, p=0.95), and weekend surgery was not associated with a LOS greater than 4 days. The two variables found to be associated with a prolonged LOS were; increasing age (RR) 1.02 (95% CI: 1.01–1.03, p<0.001) and an ASA score of 2, (RR) 1.6 (95% CI: 1.15 − 2.20, p=0.005). There was one death in a patient who was ASA III, and who underwent surgery on a Monday. There is no ‘weekend effect’ for elective orthopaedic surgery. Changes in consultant weekend working patterns are unlikely to have any effect on mortality or LOS for elective orthopaedic patients

The burden of hospital length of stay (LOS) and readmissions for total hip arthroplasty (THA) patients has resulted in great scrutiny. The purpose of this study was to determine our patients' LOS and hospital readmissions over the past 7 years. The second purpose was to determine what comorbidities affected the LOS and readmissions of 1440 THA patients. 1440 THA patients were retrospectively reviewed. The group included 622 males, 818 females. The average age of the cohort was 60 years (12 to 94 years). Ninety-day hospital readmissions were measured for the patients. Fisher's exact test, independent Sample t-test and Spearman correlation coefficients were used to determine associations of patient characteristics and comorbidities with readmission status and LOS with comorbidity status. The LOS decreased over the time of the study (p=0.02), however; readmissions remained constant at approximately 6% (p=0.73). The mean LOS for patients not readmitted was significantly shorter than for those readmitted (3.2 vs. 4.4 days; p=0.0003). Comorbidities associated with a longer hospital stay included diabetes (p=0.0052), hypertension (p=0.04), coronary artery disease (p=0.0034), congestive heart failure (p=0.0012), peripheral vascular disease (p=0.015), chronic obstructive pulmonary disease (p=0.016), renal disease (p=0.009), and mental illness (p=0.03). Increased body mass index (BMI) was not associated with a significant increase in LOS (r=0.01, p=0.83). Increased readmission rates were associated with comorbidities including hypertension (p=<0.0001), coronary artery disease (p=<0.0001), congestive heart failure (p=0.0007), peripheral vascular disease (p=<0.0001), chronic obstructive pulmonary disease (p=0.003), asthma (p=0.0128), renal disease (p=0.0001), and mental illness (p=0.0147). Obesity was not associated with increased readmission rates until the patients were morbidly obese (>40 BMI; p=0.03). Although the LOS decreased over the time of the study, this did not result in an adverse increase in readmission rates. Several comorbidities including hypertension, coronary artery disease, congestive heart failure, peripheral vascular disease, chronic obstructive pulmonary disease, and mental illness were all associated with both a longer LOS and an increase in readmission rates. Asthma was associated with increased readmission rates only and diabetes was associated with an increased LOS only. BMI was not associated with readmission rates unless the BMI exceeded 40 and had no significant effect on LOS at any BMI level

Purpose. The purpose of this study was to evaluate the effect of common medical comorbidities on the reimbursements of different shoulder arthroplasty procedures. Methods. We conducted a retrospective query of a private payer insurance claims database of prospectively collected data (PealDiver). Our search included the Current Procedural Terminology Codes (CPT) and International Classification of Disease (ICD) ninth edition codes for Total Shoulder Arthroplasty (TSA), Hemiarthroplasty (HA) and Reverse Shoulder Arthroplasty (RSA). Medical comorbidities were also searched for through ICD codes. The comorbidities selected for analysis were obesity, morbid obesity, hypertension, smoking, diabetes mellitus, hyperlipidemia, atrial fibrillation, chronic obstructive pulmonary disease (COPD), cirrhosis, depression and chronic kidney disease (CKD) (excluding end stage renal disease). The study period comprised claims from 2010 to 2014. The reimbursement charges of the day of surgery, 90-day global period and 90-day period excluding the initial surgical day of each comorbidity were analyzed and compared. Statistical analysis was conducted trough analysis of variance (ANOVA) when the data was normally distributed or through Kruskal-Wallis comparison when it was not. An alpha value of less than 0.05 was deemed as significant. Results. Comorbidities did not have a significant effect on same day reimbursements (Figure 1), but instead caused a significant effect on the 90-day global period reimbursements in the TSA and RSA cohorts (figure 2). For TSA and RSA the highest reimbursed patients at the 90-day period following surgery were the ones that had a diagnosis of Hepatitis C followed by atrial fibrillation and later COPD. For HA the same was true in the following order: Hepatitis C, Cirrhosis and atrial fibrillation (Figure 3). Conclusion. Shoulder arthroplasty reimbursements are significantly affected by comorbidities at time intervals following the initial surgical day. For figures/tables, please contact authors directly.

Aim. Periprosthetic joint infection (PJI) is a major complication of prosthetic implantation and needs a combined surgical and antimicrobial treatment. One-stage revision results usually in similar cure rate than two-stage (around 85–92%), but antibiotic therapy duration is not well established. The aim of study was to evaluate the efficacy of a short six-weeks antibiotic course in hip and knee PJIs after one-stage replacement arthroplasty (RA). Method. This was a retrospective, observational study conducted at Orthopaedic Department of Cochin Hospital, Paris, between 1stJanuary 2010 and 31 December 2015. Inclusion criteria were: age>18 years; clinical/microbiological diagnosis of PJI; one-stage RA; 6-weeks course of antibiotics; follow-up of at least one year. PJIs were classified depending on the delay of infection from implantation as: early(<3 months), delayed(3–24 months), late(>24 months). Pearson's-χ2 and t-tests were used to compare categorical and continuous variables. Results. Fifty patients with PJIs treated with one-stage hip/knee replacement arthroplasty (HRA/KRA) were included, 42 HRA, 8KRA. Median age was 69.3 years (IQR 24.5–97.4), 31 were males. Comorbidities included tumours(18%), polyarthritis(12%), chronic kidney disease (CKD), HIV infection. ASA score was ≥3 in 15(30%) cases. PJIs occurred after a mean of 36 months:9 early, 9 delayed, 32 late. Bone biopsy and synovial fluid cultures were positive for methicillin-susceptible coagulase-negative Staphylococci (MSCNS) in 19(65%) cases, methicillin-resistant CNS (MRCNS) in 5(17%), methicillin-susceptible S. aureus (MSSA) in 5(17%), P. acnes in 20(40%), Enterobacteriacae in 6(12%), Streptococcus spp. in 4(8%), E. faecium and Listeria spp.(2%). Twelve PJIs (24%) were polymicrobial. Intravenous antibiotics were administered for 11 days (IQR 4–45). Daptomycin was used in 22(44%) cases. Forty-six 46(92%) patients were switched to oral antibiotics: fluoroquinolones in 25(54%) cases, clindamycin in 19(41%), beta-lactams in 17(37%), rifampicin in 12(26%). One patient died due to a carcinoma, while others reached at least one year evaluation (IQR 12–60). Overall, the remission rate was 90%(HRA=90%, KRA=88%). Failures included 4 relapses and one reinfection: HRA in 80%, ASA score ≥3 in 40%. Infections recurred after 6 months (IQR 4–12); bacteria involved were: MSCNS(n=2), MSSA, P. acnes and ESBL-producing K. pneumoniae. Univariate analysis, performed for demographical and PJI parameters, showed no differences between success and failures, except for radiotherapy, HIV infection and CKD associated to worst prognosis (p=0.05, OR=10.7; remission rate=50%). The lowest rate of failures was observed with rifampicin use, but it was not significant(p=0.14). Conclusions. six-weeks course of antibiotics in knee and hip PJIs treated with one stage revision, seems sufficient with a satisfactory remission rate

Aims

The aim of this study was to perform the first population-based description of the epidemiological and health economic burden of fracture-related infection (FRI).

Aims

This study aims to determine difference in annual rate of early-onset (≤ 90 days) deep surgical site infection (SSI) following primary total knee arthroplasty (TKA) for osteoarthritis, and to identify risk factors that may be associated with infection.

To evaluate the efficacy of Vacuum Assisted Closure (VAC) in the management of post surgical spinal sepsis. A retrospective analysis was performed of patients with severe post operative spinal wound infections treated using a combination surgical debridement, antibiotics and VAC therapy. Full records were available for a total of twenty adult all of whom had had prior thoracic or lumbar instrumentation. Comorbidities included disseminated carcinomatosis (25 % of patients), Ankylosing spondylitis (5 %), rheumatoid arthritis (5%) and Polio (5%). In one patient there had been a prior history of irradiation of the surgical field. Most infections treated by this regime were identified within two weeks following surgery. At surgery infection deep to the dorso-lumbar fascia was found in 87 % of cases. It was possible to retain instrumentation in 60 % of cases. An average of three trips to theatre were required prior to wound closure, which was possible in 95 % of cases. The VAC device was left in situ for an average of 11 days. Complications included recurrence of infection necessitating further treatment in 20 % of cases, wound dehiscence necessitating healing by secondary intention in 5%, the need for free flap wound cover in 5 % and death from unrelated causes in 5%. VAC therapy may facilitate the management of wound sepsis following spinal surgery in susceptible patients allowing the maintenance of instrumentation and surgical correction

Introduction. Given the increasing prevalence of hip and knee arthroplasties performed, measures have been implemented to standardize care and effectively improve patient outcomes and decrease costs. Length of stay (LOS) directly affects costs. The purpose of this study was to identify peri-operative and patient related factors that correlated with decreased or increased LOS. Methods & Materials. A retrospective chart review was conducted of 289 consecutive primary total knee (TKA) and total hip (THA) arthroplasties. Comorbidities indicated by the Charlson Comorbidity Index (CCI), smoking and drinking status, age and BMI were recorded. Intraoperative and post-operative records were reviewed for American Society of Anesthesiologists (ASA) Score, anesthetic type, regional nerve blocks, and blood transfusions. The TKA cohort consisted of 57 males and 86 females, while the THA cohort consisted of 73 males and 73 females. Results. In the TKA group, the CCI was lowest in patients with LOS of 2 days and trended higher both in mean and maximum as LOS increased. In the THA group, the CCI was lower in patients with LOS of 1 or 2 days both in mean and maximum compared to patients with LOS of 3 or 4 days. Overall, patients with LOS of 3 or 4 days had a higher rate of blood transfusions compared to patients with LOS of 1 or 2 days (Table 1). There were no other notable trends. Discussion. Decreasing the LOS has shown to increase quality of life and reduce costs. Patient comorbidities as well as perioperative outcomes will impact LOS. Identifying these factors prior to or immediately after surgery may allow for more efficient triage of patients and utilization of hospital resources

Aims

Factors associated with high mortality rates in geriatric hip fracture patients are frequently unmodifiable. Time to surgery, however, might be a modifiable factor of interest to optimize clinical outcomes after hip fracture surgery. This study aims to determine the influence of postponement of surgery due to non-medical reasons on clinical outcomes in acute hip fracture surgery.

Aims

The aim of this study was to estimate time to arthroplasty among patients with hip and knee osteoarthritis (OA), and to identify factors at enrolment to first-line intervention that are prognostic for progression to surgery.

The October 2023 Hip & Pelvis Roundup³⁶⁰ looks at: Femoroacetabular impingement syndrome at ten years – how do athletes do?; Venous thromboembolism in patients following total joint replacement: are transfusions to blame?; What changes in pelvic sagittal tilt occur 20 years after total hip arthroplasty?; Can stratified care in hip arthroscopy predict successful and unsuccessful outcomes?; Hip replacement into your nineties; Can large language models help with follow-up?; The most taxing of revisions – proximal femoral replacement for periprosthetic joint infection – what’s the benefit of dual mobility?

Aims

Musculoskeletal infection is a devastating complication in both trauma and elective orthopaedic surgeries that can result in significant morbidity. Aim of this study was to assess the effectiveness and complications of local antibiotic impregnated dissolvable synthetic calcium sulphate beads (Stimulan Rapid Cure) in the hands of different surgeons from multiple centres in surgically managed bone and joint infections.