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. The aim of the study was to investigate whether the primary stability of press-fit acetabular components can be improved by altering the impaction procedure. Methods. Three impaction procedures were used to implant acetabular components into human cadaveric acetabula using a powered impaction device. An impaction frequency of 1 Hz until complete component seating served as reference. Overimpaction was simulated by adding ten strokes after complete component seating. High-frequency implantation was performed at 6 Hz. The lever-out moment of the acetabular components was used as measure for primary stability. Permanent bone deformation was assessed by comparison of double micro-CT (µCT) measurements before and after impaction. Acetabular component deformation and impaction forces were recorded, and the extent of bone-implant contact was determined from 3D laser scans. Results. Overimpaction reduced primary acetabular component stability (p = 0.038) but did not significantly increase strain release after implantation (p = 0.117) or plastic deformations (p = 0.193). Higher press-fits were associated with larger polar gaps for the 1 Hz reference impaction (p = 0.002, R. 2. = 0.77), with a similar trend for overimpaction (p = 0.082, R. 2. = 0.31). High-frequency impaction did not significantly increase primary stability (p = 0.170) at lower impaction forces (p = 0.001); it was associated with smaller plastic deformations (p = 0.035, R. 2. = 0.34) and a trend for increased acetabular component relaxation between strokes (p = 0.112). Higher press-fit was not related to larger polar gaps for the 6 Hz impaction (p = 0.346). Conclusion. Overimpaction of press-fit acetabular components should be prevented since additional strokes can be associated with increased bone damage and reduced primary stability as shown in this study. High-frequency impaction at 6 Hz was shown to be beneficial compared with 1 Hz impaction. This benefit has to be confirmed in clinical studies. Cite this article: Bone Joint J 2023;105-B(3):261–268

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

Abstract. Background. Dislocation of a hip hemiarthroplasty is a devastating complication with a high mortality rate in elderly patients. Previous studies have suggested a higher dislocation rate in patients with neuromuscular conditions. In this study, we have reviewed our larger cohort of patients to identify whether there is any association between neuromuscular disorders and prosthetic dislocation in patients treated with hip hemiarthroplasty for femoral neck fractures. Patients and Methods. Our study is a retrospective analysis of data collected over 34 years for patients with intracapsular neck of femur fracture who underwent hip hemiarthroplasty. The study population is composed of four groups: patients with no neuromuscular disorders, patients with Parkinson's disease, patients with previous stroke, and patients with dementia. Results. A total of 3827 patients were treated with hip hemiarthroplasty. For the 3371 patients with no neuromuscular condition (Group I) the dislocation rate was 1.1%. 219 patients had Parkinsonism (Group II) with a dislocation rate of 3.2%, 104 patients had a previous stroke with weakness on the fracture side with a dislocation rate of 1.0% (Group III), and 984 patients had severe dementia with a dislocation rate of 1.8% (Group IV). The increased dislocation rate for those with Parkinson's disease was statistically significant (p=0.02) while none of the other neuromuscular conditions were statistically significant. Conclusion. Our study demonstrates an increased risk of dislocation after hemiarthroplasty for patients with Parkinson's disease in comparison to other groups. No increase was apparent for those with dementia or weakness from a previous stroke

Introduction and Objective. Dislocation of a hip hemiarthroplasty is a significant complication with a high mortality rate in elderly patients. Previous studies have shown a higher risk of dislocation in patients with neuromuscular conditions. In this study, we reviewed our larger cohort of patients to identify if there is a link between neuromuscular disorders and dislocation of hip hemiarthroplasty in patients with neuromuscular conditions. Materials and Methods. We have retrospectively analysed a single-centre data that was collected over 34 years for patients with intracapsular neck of femur fracture who underwent hip hemiarthroplasty. The study population was composed of four groups: patients with no neuromuscular disorders, patients with Parkinson's disease, patients with previous stroke, and patients with mental impairment. Results. A total of 3827 patients were included in the analysis. 3371 patients had no neuromuscular condition (Group I) with a dislocation rate of 1.1%. 219 patients had Parkinsonism (Group II) with a dislocation rate of 3.2%, 104 patients had a previous stroke with weakness on the fracture side with a dislocation rate of 1.0% (Group III), and 984 patients had severe mental impairment with a dislocation rate of 1.8% (Group IV). The increased dislocation rate for those with Parkinson's disease was statistically significant (p=0.02) while none of the other neuromuscular conditions were statistically significant. Conclusions. Our study has shown an increased risk of dislocation of hemiarthroplasty in patients with Parkinson's disease in comparison to other groups. No increase was apparent for patients with mental impairment or weakness from a previous stroke

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

Aims. The primary aim of this study was to assess whether non-fatal postoperative venous thromboembolism (VTE) within six months of surgery influences the knee-specific functional outcome (Oxford Knee Score (OKS)) one year after total knee arthroplasty (TKA). Secondary aims were to assess whether non-fatal postoperative VTE influences generic health and patient satisfaction at this time. Methods. A study of 2,393 TKAs was performed in 2,393 patients. Patient demographics, comorbidities, OKS, EuroQol five-dimension score (EQ-5D), and Forgotten Joint Score (FJS) were collected preoperatively and one year postoperatively. Overall patient satisfaction with their TKA was assessed at one year. Patients with VTE within six months of surgery were identified retrospectively and compared with those without. Results. A total of 37 patients (1.5%) suffered a VTE and were significantly more likely to have associated comorbidities of stroke (p = 0.026), vascular disease (p = 0.026), and kidney disease (p = 0.026), but less likely to have diabetes (p = 0.046). In an unadjusted analysis, patients suffering a VTE had a significantly worse postoperative OKS (difference in mean (DIM) 4.8 (95% confidence interval (CI) 1.6 to 8.0); p = 0.004) and EQ-5D (DIM 0.146 (95% CI 0.059 to 0.233); p = 0.001) compared with patients without a VTE. After adjusting for confounding variables VTE remained a significant independent predictor associated with a worse postoperative OKS (DIM -5.4 (95% CI -8.4 to -2.4); p < 0.001), and EQ-5D score (DIM-0.169 (95% CI -0.251 to -0.087); p < 0.001). VTE was not independently associated with overall satisfaction after TKA (odds ratio 0.89 (95% CI 0.35 to 2.07); p = 0.717). Conclusion. Patients who had a VTE within six months of their TKA had clinically significantly worse knee-specific outcome (OKS) and general health (EQ-5D) scores one year postoperatively, but the overall satisfaction with their TKA was similar to those patients who did not have a VTE. Cite this article: Bone Joint J 2021;103-B(7):1254–1260

Cerebral Palsy (CP) is a group of disorders that affect movement and posture caused by injury to the developing brain. While prematurity and low birth weight are common causes in developed countries, birth asphyxia, kernicterus, and infections have been identified as predominant aetiologies in Africa. There is, however, very little information on the aetiology of CP in South Africa. The purpose of this study was to determine the aetiology, severity, and topographical distribution of CP in children undergoing orthopaedic surgery at our tertiary paediatric unit. A retrospective folder review was performed for patients with CP that underwent orthopaedic surgery from July 2018 to June 2022. Data was collected on perinatal circumstances, aetiology or risk factors for developing CP, severity of disability as classified by the Gross Motor Function Classification Scale (GMFCS) and topographical distribution. Descriptive analysis was performed. Two-hundred-and-thirty-four patients were included in the analysis. No specific aetiology could be identified in 51 (21.9%) patients. Hypoxic ischaemic encephalopathy (HIE) accounted for 23.6% of patients and was the most common aetiology across the different categories except for patients graded as GMFCS 2, in whom prematurity was the most common aetiology. Congenital brain malformations (10.5%) and cerebral infections, including HIV encephalopathy (11.4%) were the next most frequent aetiologies, followed by prematurity (7.6%), ischaemic stroke (6.8%) and intraventricular haemorrhage (6.3%). Fifty-two percent of patients were classified as GMFCS 4 or 5. There was a predominance of quadriplegic patients (37%) compared to hemiplegics (29%), diplegics (30%) and monoplegics (4%). Most patients undergoing orthopaedic surgery for musculoskeletal sequelae of CP were severely disabled quadriplegic patients in whom HIE was the predominant cause of CP. This emphasises the need for intervention at a primary care level to decrease the incidence of this frequently preventable condition

Introduction. VTE is a possible complication of foot and ankle surgery, however there is an absence of agreement on contributing risk factors in the development of VTE. The primary outcome of this study was to analyse the 90-day incidence of symptomatic VTE following foot and ankle surgery and to determine which factors may increase the risk of VTE. Methods. This was a national, multi-centre prospective audit spanning a collection duration of 9 months (2022/2023). Primary outcomes included incidence of symptomatic VTE and VTE related mortality up to 90 days following foot and ankle surgery and Achilles tendon rupture, and analysis of risk factors. Results. In total 11,363 patients were available for analysis. 5,090 patients (44.79%) were elective procedures, 4,791 patients (42.16%) were trauma procedures (excluding Achilles ruptures), 398 patients (3.50%) were acute diabetic procedures, 277 patients (2.44%) were Achilles ruptures undergoing surgery and 807 patients (7.10%) were Achilles ruptures treated non-operatively. There were 99 cases of VTE within 90 days of admission across the whole group (Total incidence = 0.87%), with 3 cases of VTE related mortality (0.03%). On univariate analysis, increased age and ASA grade showedhigher odds of 90-day VTE, as did previous cancer, stroke, history of VTE, and type of foot and ankle procedure / injury (p<0.05). However, on multivariate analysis, the only independent predictors for 90-day VTE were found to be the type of foot and ankle procedure (Achilles tendon rupture = Odd's Ratio 11.62, operative to 14.41, non-operative) and ASA grade (grade III/IV = Odd's Ratio 3.64). Conclusion. The incidence of 90-day post procedure VTE in foot and ankle surgery in this national audit was low. Significant, independent risk factors associated with the development of 90-day symptomatic VTE were Achilles tendon rupture management and high ASA grade

Abstract. Introduction. 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 and compare these with primary knee arthroplasty. Methodology. Primary and revision arthroplasty procedures were identified in the national Hospital Episode Statistics and were linked by patient and side. A logistic regression model was used to investigate factors associated with 90-day mortality (primary outcome) and secondary serious adverse outcomes. Urgent indications for revision arthroplasty were defined as infection or fracture; other indications (e.g. loosening, instability, wear) were included in the elective cohort. Results. 939,021 primary knee arthroplasty and 40,584 revision cases were included. Revision surgery for elective indications was associated with a 90-day rate of mortality of 0.44% (95% CI 0.37-0.52) which was comparable to primary knee arthroplasty (0.46%; 95% CI 0.44-0.47). Revision arthroplasty for infection, however, was associated with a much higher mortality of 2.04% (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% (95% CI 3.94-6.82; OR 6.23; 95% CI 4.39-8.85). Higher rates of PE, MI, and stroke were observed in the infection and fracture cohort. Conclusion. 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 with an anticipation for increased care requirements

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

Based on Ilizarov's law of tension-stress principle, distraction histogenesis technique has been widely applied in orthopaedic surgery for decades. Derived from this technique, cranial bone transport technique was mainly used for treating cranial deformities and calvarial defects. Recent studies reported that there are dense short vascular connections between skull marrow and meninges for immune cells trafficking, highlighting complex and tight association between skull and brain. Alzheimer's disease (AD) is a progressive neurodegenerative disease and the most common cause of dementia without effective therapy. Meningeal lymphatics have been recognized as an important mediator in neurological diseases. The augmentation of meningeal lymphatic drainage might be a promising therapeutic target for AD. Our proof-of-concept study has indicated that cranial bone transport can promote ischemic stroke recovery via modulating meningeal lymphatic drainage function, providing a rationale for treating AD using cranial bone maneuver (CBM). This study aims to investigate the effects of CBM on AD and to further explore the potential mechanisms. Transgenic 5xFAD mice model was used in this study. After osteotomy, a bone flap was used to perform CBM without damaging the dura. Open filed test, novel object recognition test and Barn's maze test were used to evaluate neurological functions of 5xFAD mice after CBM treatment. Congo red and immunofluorescence staining were used to evaluate amyloid depositions and Aβ plaques in different brain regions. Lymphangiogenesis and the level of VEGF-C were examined after CBM treatment. OVA-A647 was intra-cisterna-magna injected to evaluate meningeal lymphatic drainage function after CBM treatment. CBM significantly improved memory functions and reduced amyloid depositions and Aβ plaques in the hippocampus of 5xFAD mice. A significant increase of meningeal lymphatic vessels in superior sagittal sinus and transverse sinus, and the upregulation of VEGF-C in meninges were observed in 5xFAD mice treated with CBM. Moreover, CBM remarkably enhanced meningeal lymphatic drainage function in 5xFAD mice (n=5-16 mice/group for all studies). CBM may promote meningeal lymphangiogenesis and lymphatic drainage function through VEGF-C-VEGFR3 pathway, and further reduce amyloid depositions and Aβ plaques and alleviate memory deficits in AD

Aim. Patient quality of life (QoL) in untreated bone infection was compared to other chronic conditions and stratified by disease severity. Method. Patients referred for treatment of osteomyelitis (including fracture related infection) were identified prospectively between 2019 and 2023. Patients with confirmed infection completed the EuroQol EQ-5D-5L questionnaire. Clinicians blinded to EQ-index score, grouped patients according to JS-BACH Classification into ‘Uncomplicated’, ‘Complex’ or ‘Limited treatment options’. A systematic review of the literature was performed of other conditions that have been stratified using EQ-index score. Results. 257 patients were referred, and 219 had suspected osteomyelitis. 196 patients had long bone infection and reported an average EQ-index score of 0.455 (SD 0.343). 23 patients with pelvic osteomyelitis had an average EQ-index score of 0.098 (SD 0.308). Compared to other chronic conditions, patients with long-bone osteomyelitis had worse QoL when compared to different types of malignancy (including bladder, oropharyngeal, colorectal, thyroid and myeloma), cardiorespiratory disease (including asthma, COPD and ischaemic heart disease), psychiatric conditions (including depression, pain and anxiety), endocrine disorders (including diabetes mellitus), neurological conditions (including Parkinson's disease, chronic pain and radiculopathy) and musculoskeletal conditions (including osteogenesis imperfecta, fibrous dysplasia and x-linked hypophosphataemic rickets). QoL in long-bone infection was similar to conditions such as Prada-Willi syndrome, Crohn's disease and juvenile idiopathic arthritis. Patients who had a history of stroke or multiple sclerosis reported worse QoL scores compared to long-bone infection. Patients who had pelvic osteomyelitis gave significantly lower QoL scores when compared to all other conditions that were available for comparison in the literature. In long bone infection, 41 cases (21.0%) were classified as ‘Uncomplicated’, 136 (69.4%) as ‘Complex’ and 19 (9.7%) as ‘Limited treatment options available’. Within classification stratification, patients with ‘Uncomplicated’ long bone infections reported a mean EQ-index score of 0.618 (SD 0.227) which was significantly higher compared to ‘Complex’ (EQ-index: 0.410 SD 0.359, p=0.004) and ‘Limited treatment options available’ (EQ-index: 0.400 SD 0.346, p=0.007). Conclusions. Bone and joint infections have a significant impact on patient quality of life. It is much worse when compared to other common chronic conditions, including malignancy, cardiovascular and neurological diseases. This has not been previously reported but may focus attention on the need for more investment in this patient group

Aims. We studied the safety and efficacy of multimodal thromboprophylaxis in patients with a history of venous thromboembolism (VTE) who undergo total hip arthroplasty (THA) within the first 120 postoperative days, and the mortality during the first year. Multimodal prophylaxis includes discontinuation of procoagulant medications, VTE risk stratification, regional anaesthesia, an intravenous bolus of unfractionated heparin prior to femoral preparation, rapid mobilization, the use of pneumatic compression devices, and chemoprophylaxis tailored to the patient’s risk of VTE. Methods. Between 2004 to 2018, 257 patients with a proven history of VTE underwent 277 primary elective THA procedures by two surgeons at a single institution. The patients had a history of deep vein thrombosis (DVT) (186, 67%), pulmonary embolism (PE) (43, 15.5%), or both (48, 17.5%). Chemoprophylaxis included aspirin (38 patients), anticoagulation (215 patients), or a combination of aspirin and anticoagulation (24 patients). A total of 50 patients (18%) had a vena cava filter in situ at the time of surgery. Patients were followed for 120 days to record complications, and for one year to record mortality. Results. Postoperative VTE was diagnosed in seven patients (2.5%): DVT in five, and PE with and without DVT in one patient each. After hospitalization, three patients required readmiss-ion for evacuation of a haematoma, one for wound drainage, and one for monitoring of an elevated international normalized ratio (INR). Seven patients died (2.5%). One patient died five months postoperatively of a PE during open thrombectomy. She had discontinued anticoagulation. One patient died of a haemorrhagic stroke while receiving Coumadin. PE or bleeding was not suspected in the remaining five fatalities. Conclusion. Multimodal prophylaxis is safe and effective in patients with a history of VTE. Postoperative anticoagulation should be prudent as very few patients developed VTE (2.5%) or died of suspected or confirmed PE. Mortality during the first year was mostly unrelated to either VTE or bleeding. Cite this article: Bone Joint J 2020;102-B(7 Supple B):71–77

Low back pain (LBP) is a common problem in rowers of all levels. Few studies have looked at the relationship between rowing technique, the forces generated during the rowing stroke and the kinematics of spinal motion. Of particular concern with respect to spinal injury and damage are the effects of fatigue during long rowing sessions. A technique has been developed using an electromagnetic motion system and strain gauge instrumented load cell to measure spinal and pelvic motion and force generated at the oar during rowing on an exercise rowing ergometer. Using this technique 13 elite national and international oarsmen (mean age 22.43 ± 0.02 years) from local top squad rowing teams were investigated. The test protocol comprised of a one hour rowing piece. During this session rowing stroke profiles were quantified in terms of lumbopelvic kinematics and stroke force profiles. These profiles were sampled at the start of the session and quarterly intervals during the hour piece. From this data we were able to quantify the motion of the lumbar spine and pelvis during rowing and relate this to the stroke force profile. The stroke profiles over the one hour piece were then compared to examine the effects of fatigue. This revealed marked changes and increases in the amount of spinal motion during the hour piece suggesting that to maintain stroke force profiles athletes were utilising greater ranges of spinal motion. The relevance of this with regard to low back pain however, requires further investigation

Aim. To investigate self-reported quality of life (QoL) in patients with osteomyelitis referred to a specialist centre in the UK and investigate the relationship between QoL and BACH classification. Method. All patients newly referred to a specialist bone infection clinic at a single tertiary centre within the UK between January 2019 and February 2020 were prospectively included. Diagnosis of osteomyelitis was made according to the presence of clinical and radiological criteria for ≥6 months. An EQ-5D-5L questionnaire and visual analogue score (VAS) were completed during the initial clinic appointment. Long-bone osteomyelitis was classified by the attending orthopaedic surgeon using the BACH classification system as either uncomplicated, complex or with limited options available.1 Patients managed non-operatively were subclassified into those who were (i) unfit to receive an operation or (ii) fit and well with stable disease. EQ-5D index scores were compared to a published UK value set of 41 chronic health conditions within the UK.2. Results. 201 patients were referred during the study period, with 159 (79.1%) patients diagnosed with long-bone osteomyelitis and 16 (8.0%) with osteomyelitis of the pelvic bones. Patients with pelvic osteomyelitis reported lower EQ-5D index scores compared to long-bone osteomyelitis (EQ-5D: 0.097 vs. 0.435, p<0.001) but similar VAS (60.2 vs. 54.6, p=0.37). Long-bone and pelvic osteomyelitis gave the 40th and 41st lowest EQ-5D scores respectively when compared to 41 other chronic health conditions including stroke, chronic obstructive pulmonary disease, kidney disease, liver disease and malignancy. Patients classified as having uncomplicated long-bone osteomyelitis reported significantly higher QoL compared to those classified as complex osteomyelitis (EQ-5D: 0.527 vs. 0.401, p<0.05; VAS: 66.9 vs. 58.4, p<0.05). Patients who were not fit for surgery due to co-morbidity reported similar QoL scores compared to those patients with complex osteomyelitis (EQ-5D: 0.293, p=0.07; VAS: 46.6, p=0.06). Patients with stable disease who did not require surgery, gave significantly better QoL scores when compared to the other classifications of osteomyelitis (EQ-5D: 0.746, p<0.01; VAS: 81.9, p<0.01). Conclusions. Patient reported QoL in osteomyelitis correlates with disease complexity as classified according to the BACH classification system. Patients with pelvic and long-bone osteomyelitis rate their QoL lower than patients with other chronic diseases

Abstract. Objectives. Our study evaluates financial impact to the Best Practice Tariff (BPT) of hip fracture patients on Novel Oral Anti-Coagulant (NOAC) medication. Since their approval by NICE for the prevention of stroke and systemic embolism in non-valvular atrial fibrillation, the incidence of hip fracture patients admitted to hospitals on NOAC medication (e.g. rivaroxiban, apixaban) has been increasing. BPT for hip fractures has two components: a base tariff and a conditional top-up tariff of £1,335 per patient (applied to patients of 60 years of age). For the top-up tariff, six criteria must be met, of which time-to-surgery within 36 hours is one. Our department currently recommends withholding NOAC medication and delaying surgery for at least 48 hours as per our Trust's haematology guidelines to reduce intra-operative bleeding risk. Therefore, the conditional top-up tariff cannot be claimed for these patients. Method. A retrospective review of our Trust hip fracture patients over 60 years of age admitted during 2019 on NOAC medication using National Hip Fracture Database (NHFD). Results. 545 hip fracture patients had operative treatment at our Trust during the one-year period of 2019. 31 of these patients were admitted on NOAC medication, and therefore had to stop the NOAC and wait for at least 48 hours before having surgery. This translates to a potential hip fracture BPT loss of £41,385 in 2019, as the conditional top-up tariff could not be claimed. Conclusion. This study illustrates the large financial impact to BPT that hip fracture patients admitted on NOAC medications has at our Trust. It raises the argument as to whether the BPT should allow for an increased length of time until surgery for such patients, to allow safe surgical treatment with reduced bleeding risk. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Introduction. This study assesses self-reported quality of life (QoL) in patients with osteomyelitis referred to a specialist centre in the UK. Materials and Methods. All patients newly referred to a specialist tertiary bone infection clinic within the UK between January 2019 and February 2020 were prospectively included. Diagnosis of osteomyelitis was made according to the presence of clinical and radiological criteria for ≥6 months. An EQ-5D-5L questionnaire and visual analogue score (VAS) were completed during the initial clinic appointment. Long-bone osteomyelitis was classified by the attending orthopaedic surgeon using the BACH classification system as either uncomplicated, complex or with limited options available. Patients managed non-operatively were subclassified into those who were (i) unfit to receive an operation or (ii) fit and well with stable disease. EQ-5D index scores were compared to a published UK value-set of 41 chronic health conditions within the UK. Results. 201 new patients were referred during the study period. 159 (79.1%) met the criteria for long-bone osteomyelitis and 16 (8.0%) for osteomyelitis of the pelvic bones. Patients with pelvic osteomyelitis reported lower EQ-5D index scores compared to long-bone osteomyelitis (EQ-5D:0.097 vs. 0.435, p<0.001) but similar VAS (60.2 vs. 54.6, p=0.37). Long-bone and pelvic osteomyelitis gave the lowest EQ-5D scores respectively when compared to 41 other chronic health conditions including stroke, chronic obstructive pulmonary disease, kidney disease, liver disease and malignancy. Patients classified as having uncomplicated long-bone osteomyelitis reported significantly higher QoL compared to those classified as complex osteomyelitis (EQ-5D:0.527 vs. 0.401, p<0.05; VAS: 66.9 vs. 58.4, p<0.05). Patients not fit for surgery due to co-morbidity reported similar QoL scores compared to those patients with complex osteomyelitis (EQ-5D: 0.293, p=0.07; VAS: 46.6, p=0.06). Patients with stable disease who did not require surgery, gave significantly better QoL scores when compared to the other classifications of osteomyelitis (EQ-5D: 0.746, p<0.01; VAS: 81.9, p<0.01). Conclusions. Patient reported QoL in osteomyelitis correlates with disease complexity as classified according to the BACH classification system. Patients with pelvic and long-bone osteomyelitis rate their QoL lower than patients with other major chronic diseases

Aims. The aim of this study was to compare the rate of mortality and causes of death in Korean patients who undergo surgery for a fracture of the hip, up to 11 years after the injury, with a control group from the general population. Materials and Methods. National cohort data from Korean Health Insurance Review and Assessment Service – National Sample Cohort were used. A ratio of 1:4 matched patients with a fracture who underwent surgery (3383, fracture group) between 2003 and 2012, and controls (13 532) were included. The matches were processed for age, gender, income, and region of residence. We also undertook analyses of subgroups according to age and gender. The mean follow-up was 4.45 years (1 to 11). Results. The prevalence of hypertension, diabetes, and stroke was significantly higher in the fracture group and dyslipidemia in the controls. Both crude and adjusted hazard ratios (HR) for the rate of mortality in the fracture group were > 2 (crude HR 2.03, 95% confidence interval (CI) 1.91 to 2.17, p < 0.001; adjusted HR 2.07, 95% CI 1.94 to 2.21, p < 0.001). The HRs were also > 2 for both men and women, and for both those aged ≥ 50 years and < 50 years. However, for those aged < 50 years, they were insignificant. The rates of mortality due to all 11 major causes of death classified following Korean standard classification of diseases were significantly higher in the fracture group compared with the control group, except those in the mental and behavioral disorders category. Conclusion. The rate of mortality in the fracture group was significantly higher than in the control group up to 11 years after the surgery. The rate of death due to almost every major cause was significantly higher in the fracture group compared with the control group. Cite this article: Bone Joint J 2018;100-B:436–42

INTRODUCTION. Preoperative optimization and protocols for joint replacement care pathways have led to decreased length of stay (LOS), decreased narcotic use and are increasingly important in delivering quality, cost savings and shifting appropriate cases to an outpatient setting. The intraoperative use of vasopressors is independently associated with increased length of stay, risk of adverse postoperative events including death and in total hip arthroplasty there is an increased risk for ICU admission. Our aim is to characterize the patient characteristics associated with vasopressor use specifically in total knee arthroplasty (TKA). METHODS. We retrospectively reviewed 748 patients undergoing inpatient primary total knee arthroplasty at a single academic institution by two surgeons from 1/1/17 to 12/21/18. Demographics, comorbidities, perioperative factors and intraoperative medication administration were compared with multivariate regression to identify patients who may require intraoperative vasopressors. RESULTS. Seven hundred-forty eight patients underwent total knee arthroplasty and 439 patients required intraoperative vasopressors while 307 did not require vasopressors. Significant predictors of vasopressor use were male sex (p=0.035), history of prior cerebrovascular event (p=0.041) and older age (p=0.048). NPO time, anesthesia provider level of training, operative time, and intraoperative mean arterial pressure and heart rate were not significant predictors of vasopressor use intra-operatively during total knee arthroplasty. CONCLUSION. In this study, nearly fifty-nine percent of patients undergoing TKA received intraoperative vasopressor support. Male gender, history of stroke and older age were significantly associated with increased intraoperative vasopressor use. Surgical time and case order do not appear to be optimizable factors to minimize the use of vasopressors in TKA. Our results highlight variation in anesthesia practices and an opportunity to standardize vasopressor triggers and identify patients who may require vasopressor support during preoperative optimization and selection of their surgical setting

Background. There is a lack of information on the independent preoperative predictors of perioperative mortality, including the influence of previous stroke and acute coronary syndromes (myocardial infarction + unstable angina, ACS). Previous studies have grouped variables under the umbrella term “ischaemic heart disease”. In this study, we investigated the influence of vascular risk factors separately. Methods. The Hospital Episode Statistics database was analyzed for elective admissions for total hip (THR) and total knee (TKR) replacements between 2004 and 2009. Independent preoperative predictors of perioperative outcome were identified from admission secondary diagnosis codes. Perioperative mortality was defined as 30-day in-hospital death. Logistic regression analysis was used to identify independent predictors of 30-day mortality. Data was adjusted for age, social deprivation and Charlson co-morbidity score. Results. 414,985 THRs and TKRs were performed in the study period. There were 829 deaths within 30 days (0.2%). Previous ACS (OR: 1.73 [1.33 to 2.25]) and stroke (OR: 1.64 [1.02 to 2.65]) predicted 30-day mortality. ACS (OR: 3.81 [1.55 to 9.34]) within six months of THKR surgery was associated with increased odds of perioperative mortality. The effect of ACS persisted up to 12 months (OR: 1.99 [1.02 to 3.88]). Renal failure, liver disease, heart failure, peripheral vascular disease and non-atrial fibrillation arrhythmia also increased the odds of mortality. Discussion. Previous stroke and ACS increase the odds of perioperative mortality, together with several other vascular risk factors. Within 12 months of ACS, risk of mortality is significantly elevated. Elective surgery should be avoided in this period

The December 2014 Research Roundup. 360 . looks at: demineralised bone matrix not as good as we thought?; trunk control following ACL reconstruction; subclinical thyroid dysfunction: not quite subclinical?; establishing musculoskeletal function in mucopolysaccharidosis; starting out: a first year in consultant practice under the spotlight; stroke and elective surgery; sepsis and clots; hip geometry and arthritis incidence; and theatre discipline and infection

Background and purpose: Back injury is a common complaint amongst rowers. With long training hours muscle fatigue is an inevitable consequence which may be a precursor to injury. This study aims to explore the effects of fatigue on iliocostalis lumborum (IL) and superficial multifidus (SM) whilst rowing on a Concept 2C rowing ergometer (C2CRE). Method: Nineteen male athletes from Cardiff University Rowing Club were recruited fulfilling specific inclusion criteria (mean age 22yrs ± 3). Ethical approval was obtained from the institutions ethical committee. With bilateral EMG electrodes (IL and SM) attached Maximum Voluntary Contractions were collected followed by a 10 minute warm up on a C2CRE. Subjects subsequently performed a 7 stroke power test (pre fatigue condition) (. Godfrey and Williams 2007. ). Subjects then rowed at a power rate of an average power rating from the 7 stroke power test. As soon as subjects power ratings fell below 85% of the average they stopped, and then immediately performed the 7 stroke power test whilst EMG data (IL and SM) was collected (post fatigue condition). Paired T tests reported differences between pre and post fatigue scores for IL and SM. Results: A non significant trend in IL between pre and post fatigue conditions (p=0.065) was noted with no significant difference in SM activity (p=0.196). Conclusion: This study has provided evidence that there is a difference in muscle activity between IL and SM following a fatiguing protocol, which may play an important role in the understanding of mechanisms leading to low back pain in rowers

In a prospective, controlled study, we measured the effect on cardiac output of the introduction of methylmethacrylate during hemiarthroplasty for displaced fractures of the femoral neck. We treated 20 elderly patients who were similar in age, height, weight and preoperative left ventricular function with either cemented or uncemented hemiarthroplasty. Using a transoesophageal Doppler probe, we measured cardiac output before incision and at six stages of the procedure: during the surgical approach, reaming and lavage of the femoral canal, the introduction of cement, the insertion of the prosthesis, and in reduction and closure. We found that before the cement was introduced, there was no difference in stroke volume or cardiac output (p > 0.25). Cementation produced a transient but significant reduction in cardiac output of 33% (p < 0.01) and a reduction in stroke volume of 44% (p < 0.02). The introduction of cement did not affect the heart rate or mean arterial pressure. There was no significant difference in cardiac function on insertion of the prosthesis. Standard non-invasive haemodynamic monitoring did not detect the cardiovascular changes which may account for the sudden deaths that sometimes occur during cemented hemiarthroplasty. The fall in stroke volume and cardiac output may be caused by embolism occurring during cementation, but there was no similar fall during reaming or insertion of the prosthesis

Joint hemiarthroplasty replaces one side of a synovial joint and is a viable alternative to total joint arthroplasty when one side of the joint remains healthy. Most hemiarthroplasty implants used in current clinical practice are made from stiff materials such as cobalt chrome or ceramic. The substitution of one side of a soft cartilage-on-cartilage articulation with a rigid implant often leads to damage of the opposing articular cartilage due to the resulting reductions in contact area and increases in cartilage stress. The improvement of post-operative hemiarthroplasty articular contact mechanics is of importance in advancing the performance and longevity of hemiarthroplasty. The purpose of the present study was to investigate the effect of hemiarthroplasty surface compliance on early in-vitro cartilage wear and joint contact mechanics. Cartilage wear tests were conducted using a six-station pin-on-plate apparatus. Pins were manufactured to have a hemispherical radius of curvature of 4.7 mm using either Bionate (DSM Biomedical) having varying compliances (80A [E=20MPa], 55D [E=35MPa], 75D [E=222MPa], n=6 for each), or ceramic (E=310GPa, n=5). Cartilage plugs were cored from fresh unfrozen bovine knee joints using a 20 mm hole saw and mounted in lubricant-containing chambers, with alpha calf serum diluted with phosphate buffer solution to a protein concentration of 17 g/L. The pins were loaded to 30N and given a stroke length of 10 mm for a total of 50,000 cycles at 1.2 Hz. Volumetric cartilage wear was assessed by comparing three-dimensional cartilage scans before and during wear testing. A two-way ANOVA was used for statistical analysis. To assess hemiarthroplasty joint contact mechanics, 3D finite element modelling (ABAQUS v6.12) was used to replicate the wear testing conditions. Cartilage was modeled using neo-Hookean hyper-elastic material properties. Contact area and peak contact stress were estimated. The more compliant Bionate 80A and 55D pins produced significantly less volumetric cartilage wear compared with the less compliant Bionate 75D and ceramic pins (p 0.05). In terms of joint contact mechanics, the more compliant materials (Bionate 80A and 55D) had significantly lower maximum contact stress levels compared to the less compliant Bionate 75D and ceramic pins (p < 0 .05). The results of this study show a relationship between hemiarthroplasty implant surface compliance and early in vitro cartilage wear, where the more compliant surfaces produced significantly lower amounts of cartilage wear. The results of the joint contact mechanics analysis showed that the more compliant hemiarthroplasty materials produced lower maximum cartilage contact stresses than the less compliant materials, likely related to the differences in wear observed. More compliant hemiarthroplasty surfaces may have the potential to improve post-operative cartilage contact mechanics by increasing the implant-cartilage contact area while reducing peak contact stress at the implant-cartilage interface, however, such materials must be resistant to surface fatigue and longer-term cartilage wear/damage must be assessed

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

Up to 40% of patients are using opioids at the time of joint replacement surgery in the USA despite emerging evidence suggesting opioids are ineffective for chronic non-cancer pain. Our primary objective was to determine if preoperative opioid use among patient awaiting total knee arthroplasty (TKA) was associated with worse patient-reported outcomes (PRO) measures at one-year follow-up when compared to non-opioid users, after adjusting for age, gender, and comorbidities. The study linked Alberta's Pharmacy Information Network (PIN) data with prospectively collected Alberta Bone and Joint Health Repository administrative data (medical and PRO data) for patients who underwent primary TKA in Alberta from 2013–2015. The PIN contains prescribing information from physician offices and pharmacies across Alberta. Preoperative ‘opioid users’ were defined as having 90-days of consistent opioid use in the 180-days prior TKA, and ‘opioid-exposed’ subjects had recorded opioid prescriptions in the 180-days prior to TKA, but did not meet the definition of an opioid user. Those with no opioid-exposure in the 180-days pre-TKA were deemed a ‘non-opioid user’. We used multiple linear regression to examine how preoperative opioid use (opioid user, opioid-exposed, non-opioid user) impacted Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function scores at one year after TKA after adjusting for confounding variables. These included age, sex, preoperative WOMAC scores, comorbidities including depression, diabetes, obesity, stroke, pulmonary disease, renal disease, cardiac disease, liver disease, and overall comorbid burden. Of the 2182 unique cases identified, 151 (7%) were opioid users, 527 (24%) opioid-exposed and 1504 (69%) non-opioid user. Opioid users were more likely to be prescribed strong opioids (e.g., hydromorphone, oxycodone) compared to with opioid-exposed subjects (p < 0 .001) and had a median morphine equivalent dose of 30.7 mg/day compared with the opioid-exposed group (2.2 mg/day, p < 0 .001) in the 180-days prior to TKA. Opioid users, in the 180-days prior to TKA had an active opioid prescription for a mean duration of 153 days (95CI 149, 157) within the 180-days prior to TKA, compared to 34 days (95CI 32, 37) for opioid-exposed (p < 0 .001). In the parsimonious pain and function models, opioid use, lower preoperative WOMAC score, depression, and obesity were associated with worse one-year pain and function. Patients prescribed preoperative opioids had worse WOMAC scores one-year after TKA respectively when compared to non-opioid users, after adjusting for other factors (opioid user pain score: −9.5, function score: −9.4, opioid exposed pain score: −2.6, function score: −3.6, p < 0 .001 for all). Further, opioid users with a concomitant diagnosis of depression had significantly worse one-year postoperative WOMAC scores when compared to non-depressed non-opioid users (scores −14, p < 0 .001 for both pain and function). In Alberta, 31% of patients were prescribed opioids within 180-days before TKA, preoperative opioid use was associated with worse one-year postoperative WOMAC pain and function scores relative to non-opioid users. Our results suggest that strategies to reduce preoperative opioid use could improve patient outcomes after TKA, and support the most recent Canadian opioid prescribing guidelines that attempt to minimize opioid use for chronic conditions such as arthritis

Up to 40% of patients are using opioids at the time of joint replacement surgery in the USA despite emerging evidence suggesting opioids are ineffective for chronic non-cancer pain. Our primary objective was to determine if preoperative opioid use among patient awaiting total knee arthroplasty (TKA) was associated with worse patient-reported outcomes (PRO) measures at one-year follow-up when compared to non-opioid users, after adjusting for age, gender, and comorbidities. The study linked Alberta's Pharmacy Information Network (PIN) data with prospectively collected Alberta Bone and Joint Health Repository administrative data (medical and PRO data) for patients who underwent primary TKA in Alberta from 2013–2015. The PIN contains prescribing information from physician offices and pharmacies across Alberta. Preoperative ‘opioid users’ were defined as having 90-days of consistent opioid use in the 180-days prior TKA, and ‘opioid-exposed’ subjects had recorded opioid prescriptions in the 180-days prior to TKA, but did not meet the definition of an opioid user. Those with no opioid-exposure in the 180-days pre-TKA were deemed a ‘non-opioid user’. We used multiple linear regression to examine how preoperative opioid use (opioid user, opioid-exposed, non-opioid user) impacted Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function scores at one year after TKA after adjusting for confounding variables. These included age, sex, preoperative WOMAC scores, comorbidities including depression, diabetes, obesity, stroke, pulmonary disease, renal disease, cardiac disease, liver disease, and overall comorbid burden. Of the 2182 unique cases identified, 151 (7%) were opioid users, 527 (24%) opioid-exposed and 1504 (69%) non-opioid user. Opioid users were more likely to be prescribed strong opioids (e.g., hydromorphone, oxycodone) compared to with opioid-exposed subjects (p < 0 .001) and had a median morphine equivalent dose of 30.7 mg/day compared with the opioid-exposed group (2.2 mg/day, p < 0 .001) in the 180-days prior to TKA. Opioid users, in the 180-days prior to TKA had an active opioid prescription for a mean duration of 153 days (95CI 149, 157) within the 180-days prior to TKA, compared to 34 days (95CI 32, 37) for opioid-exposed (p < 0 .001). In the parsimonious pain and function models, opioid use, lower preoperative WOMAC score, depression, and obesity were associated with worse one-year pain and function. Patients prescribed preoperative opioids had worse WOMAC scores one-year after TKA respectively when compared to non-opioid users, after adjusting for other factors (opioid user pain score: −9.5, function score: −9.4, opioid exposed pain score: −2.6, function score: −3.6, p < 0 .001 for all). Further, opioid users with a concomitant diagnosis of depression had significantly worse one-year postoperative WOMAC scores when compared to non-depressed non-opioid users (scores −14, p < 0 .001 for both pain and function). In Alberta, 31% of patients were prescribed opioids within 180-days before TKA, preoperative opioid use was associated with worse one-year postoperative WOMAC pain and function scores relative to non-opioid users. Our results suggest that strategies to reduce preoperative opioid use could improve patient outcomes after TKA, and support the most recent Canadian opioid prescribing guidelines that attempt to minimize opioid use for chronic conditions such as arthritis

Introduction. We studied the safety and efficacy of multimodal thromboprophylaxis (MMP) in patients with a history of venous thromboembolism (VTE) undergoing total hip arthroplasty (THA). MMP includes discontinuation of procoagulant medications, VTE risk stratification, regional anesthesia, an intravenous bolus of unfractionated heparin before femoral work, rapid mobilization, the use of pneumatic compression devices, and chemoprophylaxis tailored to the patient's risk. Material and methods. From 2004 to 2018, 257 patients (mean age: 67 years; range: 26–95) with a history of VTE underwent 277 primary, elective THAs procedures (128 right, 100 left, 9 single-stage bilateral, 20 staged bilateral) by two orthopaedic surgeons at a single institution. The patients had a history deep vein thrombosis (DVT) 186 (67%), pulmonary embolism (PE) 43 (15.5%), or both 48 (17.5%). Chemoprophylaxis included aspirin (38 patients) and anticoagulation (239 patients; Coumadin: 182, low-molecular-weight heparin: 3, clopidogrel: 1, rivaroxaban: 3, and a combination: 50). Forty eight patients (17.3%) had a vena cava filter at the time of surgery. Patients were followed for 120 days to detect complications, and for a year to detect mortality. Results. Postoperative VTE was diagnosed in seven patients (2.5%): DVT in five, and PE with and without DVT in one patient each. Bleeding complications occurred in 2 patients, one requiring surgical evacuation of a hematoma. Seven patients died during the first year (2.5%). One patient died 5 months postoperatively of a fatal PE during open thrombectomy, and one patient died of a hemorrhagic stroke while receiving Coumadin. PE or bleeding was not suspected in any of the remaining 5 fatalities. Conclusions. The result of this study spanning over 13 years, suggests that MMP is safe and effective. Postoperative anticoagulation should be prudent as very few patients developed postoperative VTE (2.5%) or died of suspected or confirmed PE. Mortality during the first year was mostly unrelated to VTE or bleeding. For any tables or figures, please contact the authors directly

Using general practitioner records and hospital notes and through direct telephone conversation with patients, we investigated the accuracy of nine patient-reported complications gathered from a self-completed questionnaire after elective joint replacement surgery of the hip and knee. A total of 402 post-discharge complications were reported after 8546 elective operations that were undertaken within a three-year period. These were reported by 136 men and 240 women with a mean age of 71.8 years (34 to 93). A total of 319 reported complications (79.4%; 95% confidence interval 75.4 to 83.3) were confirmed to be correct. High rates of correct reporting were demonstrated for infection (94.5%) and the need for further surgery (100%), whereas the rates of reporting deep-vein thrombosis (DVT), pulmonary embolism, myocardial infarction and stroke were lower (75% to 84.2%). Dislocation, peri-prosthetic fractures and nerve palsy had modest rates of correct reporting (36% to 57.1%). More patients who had knee surgery delivered incorrect reports of dislocation (p = 0.001) and DVT (p = 0.013). Despite these variations, it appears that post-operative complications may form part of a larger patient-reported outcome programme after elective joint replacement surgery

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

Background. Standard preoperative protocols in total joint arthroplasty utilize the International Normalized Ratio (INR) to determine patient coagulation profiles. However, the relevance of preoperative INR values in joint arthroplasty remains controversial. Acceptable INR cutoff values for joint replacement are inconsistent, and are often based on studies of primary arthroplasty, or even non-orthopedic procedures. This analysis examined the relationship between preoperative INR values and post-operative outcomes in revision total hip arthroplasty (rTHA). Optimal cutoff INR values correlated with specific outcomes were subsequently determined. Methods. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) was retrospectively queried for revision total hip arthroplasty procedures performed between 2006 and 2017. Patients with a preoperative INR collected no later than 1 day prior to surgery were further stratified for analysis. INR values which correlated with specific outcomes were determined using receiver operating characteristics (ROC) curves for each outcome of interest. The optimal cutoff INR value for each outcome was then obtained using univariate and multivariate models which determined INR values that maximized both sensitivity and specificity. Results. There were a total of 11,393 patients who underwent a revision total hip arthroplasty from 2006–2017 recorded in NSQIP. Of the 2,012 patients who met inclusion and exclusion criteria, 858 had an INR < 1.0, 931 had an INR > 1.0 to 1.25, 175 had an INR > 1.25 to 1.5, and 48 patients had an INR > 1.5. Patients with progressively higher INR values had a significantly different risk of mortality within 30 days (p=0.005), bleeding requiring transfusion (p< 0.001), sepsis (p=0.002), stroke (p<0.001), failure to wean from ventilator within 48 hours (p=0.001), readmission (p=0.01), and hospital length of stay (p< 0.001). Similar results were obtained when utilizing optimal INR cutoff values. When correcting for other factors, the following poor outcomes were significantly associated with the respective INR cutoff values (Estimate, 95% CI, p value): LOS (1.67, 1.34–2.08, p <0.001), bleeding requiring transfusion (1.65, 1.30–2.09, p<0.001), sepsis (2.15, 1.11–4.17, p 0.02), and any infection (1.82, 1.01–3.29, p 0.04). Conclusions. INR values >1.65, >1.67, >1.82, and >2.15 were correlated with increased transfusion requirements, LOS, any infection, and sepsis respectively. Therefore, even subtherapeutic elevations in INR may predict poor outcomes following revision total joint replacement. Surgeons and perioperative medical specialists should consider more stringent INR goals when optimizing patients prior to revision arthroplasty. Level of Evidence. Prognostic Level IV. For any figures or tables, please contact authors directly

Between January 1996 and December 2006, 130 patients were operated on for acquired varus equinus foot deformity. The most frequent aetiologies were stroke or brain damage due to head trauma. The primary indications for surgery included pain, caused by pressure of the foot or toes on the floor or in shoes, ankle instability due to varus deformity, or difficulty wearing orthopaedic shoes or braces. Split anterior tibial transfer was generally done after lengthening of Achillis tendon and tenotomy of long and short toe flexors during the same session. The author did compare preoperative and postoperative autonomy, and shoe or orthosis requirements. The results of this study include significant improvement in patient autonomy demonstrated by an improved ability to ambulate independently and a decreased need to wear orthopedic shoes and orthoses, as well as an increased ability to wear normal shoes, or the ability to ambulate bare foot. Adequate knee flexion during swing phase of the stride was the best indicator for better result. This procedure is safe and yields good results with minimal complications. The indications are very common, inasmuch as the number of young hemiplegic patients surviving after a stroke or head injury is increasing. This procedure can result in definite improvement for these disabled patients and can increase their autonomy

Introduction: To quantify the magnitude and incidence of haemodynamic changes that occurs during the fixation of extracapsular proximal femoral fractures when using either intra-medullary or extra-medullary fixation device. Methods: A prospective group of 31 patients with extra-capsular proximal femoral fractures were randomised to either fixation using an extra-medullary compression hip screw or an intra-medullary hip screw. All patients received a general anaesthetic adhering to a standardised anaesthetic protocol including invasive blood pressure monitoring and arterial blood gas sampling. Trans-oesophageal Doppler probe and monitor was used to record pre-operative hypovolaemia and peri-operative changes in cardiac output, stroke volume and corrected flow time (FTc – a reflection of left ventricular end diastolic pressure) during placement of implants. Results: 77% of patients were hypovolaemic preoperatively, which was corrected with an average of 439 mls of colloid replacement fluid. Application of the extra-medullary CHS produced no change in haemodynamic function. However on insertion of the IMHS we found a statistically significant reduction in stroke volume, cardiac output and FTc without changes in pulse rate or mean arterial pressure. The changes were transient with normal cardiac function returning by 5 mins post operatively. Conclusion: The transient fall in cardiac function during insertion of the intramedullary hip screw may be caused by fat embolism entering the venous circulation. As these changes are not detected with standard non-invasive monitoring we would recommend that intramedullary devices be used with caution in elderly patients who tend to have poor physiological reserve

The subject of central nervous system damage includes a wide variety of problems, from the slow selective ‘picking off’ of characteristic sub-populations of neurons typical of neurodegenerative diseases, to the wholesale destruction of areas of brain and spinal cord seen in traumatic injury and stroke. Experimental repair strategies are diverse and the type of pathology dictates which approach will be appropriate. Damage may be to grey matter (loss of neurons), white matter (cutting of axons, leaving neurons otherwise intact, at least initially) or both. This review will consider four possible forms of treatment for repair of the human central nervous system

Objectives. The primary purpose of this meta-analysis was to determine whether statin usage could reduce the risk of glucocorticoid-related osteonecrosis in animal models. Methods. A systematic literature search up to May 2015 was carried out using the PubMed, Ovid, EBM reviews, ISI Web of Science, EBSCO, CBM, CNKI databases with the term and boolean operators: statins and osteonecrosis in all fields. Risk ratio (RR), as the risk estimate of specific outcome, was calculated along with 95% confidence intervals (CI). The methodological quality of individual studies was assessed using a quantitative tool based on the updated Stroke Therapy Academic Industry Roundtable (STAIR) recommendations. Results. A total of 11 eligible studies were included according to predetermined criteria. The pooled data demonstrated that animals with statin usage, either alone or combined with other treatments, were at a decreased risk of developing glucocorticoid-related osteonecrosis (RR = 2.06, 95% confidence interval (CI) 1.71 to 2.50). Moreover, subgroup analysis revealed that compared with statins alone, statins combined with other treatments significantly decreased the risk of osteonecrosis (RR = 1.23, 95% CI 1.02 to 1.47). However, we could find no significant risk difference for different gender, or for different time points. Conclusions. The present study suggests that statins combined with other treatments are efficient in preventing the development of glucocorticoid-related osteonecrosis in animals. These results might shed light on clinical practice when glucocorticoids are prescribed, and could be further investigated in high-quality clinical trials. Cite this article: Z. Yang, H. Liu, D. Li, X. Xie, T. Qin, J. Ma, P. Kang. The efficacy of statins in preventing glucocorticoid-related osteonecrosis in animal models: A meta-analysis. Bone Joint Res 2016;5:393–402. DOI: 10.1302/2046-3758.59.2000500

Introduction. Historically, US arthroplasty revision rates are based on CMS data that cannot verify initial surgery date in patients under 65 years or laterality of revision. We calculated US one-year revision rates for primary total hip replacement (THR) using a representative cohort. Reasons for revision were documented. Methods. A multi-center cohort from US surgeons in 28 states collected sociodemographic data; medical, emotional, musculoskeletal comorbidities; BMI; and patient-reported pain and function (SF36, HOOS) for elective THR patients. Cases in 2011–2013 were matched with CMS data to ascertain 1 year revision through 2014. Predictors of revision were identified. Chart reviews to verify reasons for revision were performed. Results. Overall, 1.6% of 2926 primary THR surgeries were revised within 12 months. Mean age was 72 years, 59% female. No significant difference in pre-operative age, sex, BMI, pain, function, or emotional health was detected between revision and non-revision patients. Severe low back pain was twice as prevalent among revisions (23% vs. 11%; p<0.04) as was prior stroke (8.5% vs. 3%). Primary reasons for revision were infection (30%), mechanical failure including dislocation (26%), fracture (19%), metal ions (15%) and other (10%). In patients under 65 years of age, the distribution of reasons for revision are identical. Conclusion. The incidence of revision THR in the US within 12 months of the index procedure is 1.6%. Infection and mechanical failure, including dislocation, are the most common causes of early revision, followed by peri-prosthetic fracture. Patients with severe pre-op lumbar spine pain are at higher risk for early revision after THR. Abbreviations: total hip replacement (THR)

Aims

The aim of this study was to investigate the association between additional rehabilitation at the weekend, and in-hospital mortality and complications in patients with hip fracture who underwent surgery.

Purpose. Total knee replacement is the one of the most performed surgeries. However, patient's satisfaction rate is around 70–90 % only. The sacrifice of cruciate ligament might be the main reason, especially in young and active patients. ACL stabilizes the knee by countering the anterior displacing and pivoting force, absorbs the shock and provides proprioception of the knee. However, CR knees has been plagued by injury of PCL during the surgery and preservation of the ACL is a demanding technique. Stiffness is more common comparing to PS designed knee. To insert a tibial baseplate with PE is usually thicker than 8 mm comparing to 2–4 mm of removed tibial bone. The stuffing of joint space may put undue tension on preserved ACL and PCL. Modern designed BCR has been pushed onto market with more sophisticated design and instrumentation. However, early results showed high early loosening rate. Failure to bring the tibia forward during cementing may be the main cause. The bone island where ACL footprint locates is frequently weak, intraoperative fracture happens frequently. A new design was developed by controlled elevation and reattachment of the ACL footprint to meet all the challenges. Method. A new tibial baseplate with a keel was designed. The central part of the baseplate accommodates elevated bony island with ACL footprint. The fenestrations at the central part is designed for reattachment of bony island under proper tension with heavy sutures and fixed at anterior edge of the baseplate in suture bridge fashion and also for autograft to promote bony healing after reattachment. The suture bridge method has been used by arthroscopists for ACL avulsion fracture without the need of immobilization. The elevation of bony island release the tension in the ACL which come from stuffing of baseplate and PE insert and greatly facilitate cementing of the baseplate. The keel improve the weakness of traditional U shape design of BCR knees. Instead of keeping the bony island intact by separately cutting the medial and lateral tibial plateau in BCR knees in the past, we choose to saw the tibial plateau in one stroke as in PS knees, then removes the two condyles. The bony island includes the footprint both ACL and PCL. The central part of tibial baseplate will push the bony island upward which release the undue tension in the cruciate ligaments. Summary. We proposed a new solution for the kinematic conflict in the present bi-cruciate knee designs by elevation and re- attachment of bony island with ACL footprint at the same time simplify the ACL preservation. The simple tibial cutting procedure also facilitate the process. The technique protects PCL from injury during tibial bone cutting in CR knees. We believe the new BCR design has the potential to replace CR knee in term of function and longevity in the future

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

Aims

The escalating demand for medical resources to address spinal diseases as society ages is an issue that requires careful evaluation. However, few studies have examined trends in spinal surgery, especially unscheduled hospitalizations or surgeries performed after hours, through large databases. Our study aimed to determine national trends in the number of spine surgeries in Japan. We also aimed to identify trends in after-hours surgeries and unscheduled hospitalizations and their impact on complications and costs.

Aims

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

Spasticity is a complex syndrome requiring extensive and complete treatment. Injections of botulinum toxin type A decrease muscle tone in spastic muscles of the hand and improve the use of the upper limb. However, rehabilitation and different non-invasive treatments should also be considered. Shock waves are defined as a sequence of single sonic pulses characterised by high peak pressure (100 MPa), fast pressure rise (< 10 ns) and short duration (10 μs). Twenty patients, with upper limb spasticity post stroke were enrolled in the study. The patients (12 men and eight women) had a mean age of 63 years (36–76 years). An electromagnetic coil lithotriptor (Modulith SLK® by Storz Medical AG) provided with in-line ultrasound, radiographic, and computerised aiming (Lithotrack® system) was used. Flexor muscles of the forearm were treated with 1500 shots, and 3200 shots were used for interosseous muscles of the hand (800 for each muscle). The energy applied was 0.030 mj/mm. The protocol consisted of one placebo treatment session in which no shock waves were applied, followed 1 week later by one active shock wave treatment session. The Ashworth Scale was used to study the muscle tone activity in patients. No changes in the Ashworth score were noted in hand and wrist flexion after placebo stimulation. After real treatment the hand muscles and finger flexion in particular showed a marked reduction in spasticity with a change in the Ashworth scale from 3 to 0. At 1, 4, and 12 weeks, a slight increase in muscle tone was observed for all subjects. Needle EMG was performed at 4 weeks. No denervation was observed. The main finding of this preliminary study is that a single active treatment of shock wave therapy in spastic muscles in a patient affected by stroke resulted in a significant reduction in muscle tone. In contrast, no effect was noted after placebo stimulation. Nitric oxide synthesis has been suggested to be one of the most important mechanisms to explain the effectiveness of shock waves in the treatment of different soft tissue diseases. Shock wave therapy appeared to be safe, non invasive and without complications. Our findings suggest that shock wave therapy may be useful in decreasing flexor tone and functional disability in patients with spasticity of the hand, with a long-lasting effect. This therapy could open a new field of research in the treatment of spasticity. Further studies with a larger group of patients are, therefore, necessary

The August 2024 Knee Roundup³⁶⁰ looks at: Calcification’s role in knee osteoarthritis: implications for surgical decision-making; Lower complication rates and shorter lengths of hospital stay with technology-assisted total knee arthroplasty; Revision surgery: the hidden burden on surgeons; Are preoperative weight loss interventions worthwhile?; Total knee arthroplasty with or without prior bariatric surgery: a systematic review and meta-analysis; Aspirin triumphs in knee arthroplasty: a decade of evidence; Efficacy of DAIR in unicompartmental knee arthroplasty: a glimpse from Oxford.

Heterotopic ossification (HO) is a relatively common complication of total hip arthroplasty (THA), but is rather rare after total knee arthroplasty (TKA). In both cases, it is usually asymptomatic and is most commonly identified as an incidental finding on post-operative radiographs. However, in severe cases it can result in decreased range of motion and pain. There are several risk factors that have been shown to be associated with development of HO. These include male gender, ceramic-on-ceramic bearings, prior stroke, and hypertrophic osteoarthritis. Heterotopic ossification can be treated with physical therapy during the maturation phase (12 to 24 weeks), but surgical intervention is required if the stiffness persists. All heterotopic bone should be excised with careful attention to neurovascular structures. Patients should begin prophylaxis following HO excision and prior to any subsequent surgeries. Heterotopic ossification prophylaxis consists of NSAIDs, radiotherapy, or a combination of both modalities. These therapies are not without complications, therefore, routine administration of prophylaxis for all patients is not indicated. Several new pathways of inhibiting extra-skeletal bone formation in HO are under investigation (retinoid acid receptor agonists, apyrase, and LDN-193189). Future studies should focus on identification of patients at risk for HO as well as better therapeutic options with less side effects

Use of large databases for orthopaedic research has increased exponentially. Each database represents unique patient populations and vary in methodology of data acquisition. The purpose of this study was to evaluate differences in reported demographics, comorbidities and complications following total hip arthroplasty (THA) amongst four commonly used databases. Patients who underwent primary THA during 2010–2012 were identified within National Surgical Quality Improvement Programs (NSQIP), Nationwide Inpatient Sample (NIS), Medicare Standard Analytic Files (MED) and Humana Claims Database (HAC). NSQIP definitions for comorbidities and surgical complications were queried in NIS, MED, and HAC using coding algorithms. Age, sex, comorbidities, inpatient and 30-day postoperative complications were compared (NIS has inpatient data only). Primary THAs from each database were 22,644 (HAC), 371,715 (MED), 188,779 (NIS) and 27,818 (NSQIP). Age and gender distribution were similar between databases. There was variability in the prevalence of comorbidities and complications depending upon the database and duration of post-operative follow-up. HAC and MED had twice the prevalence of COPD, coagulopathy and diabetes than NSQIP. NSQIP had more than twice the obesity than NIS. HAC had more than twice the rates of 30-day complications at all endpoints compared to NSQIP and more than twice the DVTs, strokes and deep infection as MED at 30-days post-op. Comparison of inpatient and 30-day complications rates demonstrated more than twice the amount of infections and DVTs are captured when analysis is extended from inpatient stay to 30-days post-op. Amongst databases commonly used in orthopaedic research, there is considerable variation in complication rates following THA depending upon the database. It will be important to consider these differences when critically evaluating database research. Additionally, with the advent of bundled payments, these differences must be considered in risk adjustment models

Aims

The aim of this study was to characterize the influence of social deprivation on the rate of complications, readmissions, and revisions following primary total shoulder arthroplasty (TSA), using the Social Deprivation Index (SDI). The SDI is a composite measurement, in percentages, of seven demographic characteristics: living in poverty, with < 12 years of education, single-parent households, living in rented or overcrowded housing, households without a car, and unemployed adults aged < 65 years.

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

Aims

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