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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Introduction. This study was designed to evaluate the effect of discharge timing on 30-day major and minor complications in patients undergoing total knee arthroplasty (TKA) while adjusting for other variables. Methods. Patients 18 years and older undergoing TKA between the years of 2005 and 2016 were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). Patients whose length of stay (LOS) was >4 days were excluded. Patient demographics, anesthesia type, length of operation and hospital stay, as well as 30-day major and minor complications were collected from the database. Chi square tests were utilized to compare the unadjusted rates of complications between patients whose LOS was 0, 1, 2, and 3–4 days. Multivariable regression was utilized to evaluate the effect of LOS on complication rates, while adjusting for age, American Society of Anesthesiologist (ASA) class, type of anaesthesia, functional status, comorbidities, sex, steroid/immunosuppressant use, body mass index (BMI), diabetes, length of operation and smoking status. Results. A total of 198,191 TKA patients were identified (average age 66 ± 10 years). Average LOS was 2.5 ± 0.81 days. Of these patients, 1,667 (0.84%) were discharged the day of surgery, while 16,186 (8.17%) were discharged one-day post-surgery, 63,540 (32.06%) were discharged on day two, and 115,471 (58.25%) were discharged between 3 and 4 days post-surgery. Unadjusted rates of complications were significantly higher for patients who were discharged on the day of surgery (2.64%), or those whose LOS was 3–4 days (2.78%) compared to those whose LOS was 1 (1.40%) or 2 days (1.67%). After adjusting for all relevant covariables, discharge on the day of surgery increased the risk of major complications by 1.8 (95% Confidence interval [95%CI] 1.2–2.8), and minor complications by 1.6 (95%CI 1.2 – 2.2) compared to patients whose LOS was 2 days. A LOS of 1 day did not affect the risk of major complications compared to a LOS of 2 days, while a LOS of 3–4 days increased the risk of major complications by 1.4 (95%CI 1.3 – 1.6), and minor complications by 1.6 (95%CI 1.4 – 1.7). Regarding specific complications, same-day discharge remained an independent predictor of myocardial infarction (MI), cardiac arrest, pulmonary embolism (PE), unplanned reintubation, >48 hours on ventilator, pneumonia and renal insufficiency, while a LOS of 3–4 days remained an independent predictor of MI, cardiac arrest, sepsis, acute renal failure, PE, unplanned reintubation, >48 hours on ventilator, stroke, deep vein thrombosis, pneumonia, urinary tract infection, renal insufficiency, deep and superficial surgical site infection, and wound disruption compared to patients whose LOS was 2 days (p<0.01). Conclusion. Discharge on days 1–2 postoperatively following TKA appears to have superior outcomes compared to discharge on the day of surgery, or on days 3–4. Prospective clinical data is required to confirm the effect of discharge timing on postoperative outcomes following TKA

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

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

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

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

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

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

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

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