Introduction. We implemented an exhaustive operative and supervision algorithm for surgical treatment of hip fractures primarily based on own previously published literature. The purpose was to improve supervision and reduce the rate of reoperations. Materials and methods. 2000 consecutive unselected patients above 50 years admitted with a hip fracture were included, 1000 of these prospectively after implementation of the algorithm. Demographic parameters, hospital treatment and reoperations within the first postoperative year were assessed from patient records. The algorithm dictated the surgical treatment based on three objective patient parameters: age, new mobility score and fracture classification on pre-operative anterior-posterior and axial radiographs. Intra capsular fractures were treated with two parallel implants, a sliding hip screw, an arthroplasty or resection of the femoral head. Extra capsular fractures were treated with a sliding hip screw or an intramedullary nail. Supervision of junior registrars was mandatory for the prosthesis and intramedullary nail procedures. Results. 931/1000 operative procedures were operated according to the algorithm, compared to only 726/1000 prior to its introduction (p<0.001). Retrospectively we found that 13% (208/1657) of operative procedures performed as the algorithm dictated were reoperated compared to 28% (96/343) of operative procedures performed with other methods (p<0.001). In logistic regression analysis combining sex, age, ASA score, cognitive function, new mobility score and level of surgeon's experience, not following the algorithm was a predictor for re-operation (p<0.001 log. reg.). After implementing the algorithm, junior registrars still performed half of the operations, but unsupervised procedures declined from 192/1000 to 105/1000 (p=0.039). The rate of reoperations declined from 18% to 12% (p<0.001, log. reg.), with a 24% (112/467) to 18% (87/482) decline for intra capsular fractures (p=0.025) and a 13% (68/533) to 7% (37/518) decline for extra capsular fractures (p=0.002). The extra bed-days caused by reoperations were hereby reduced from 24% to 18% of total hospitalization. Conclusion. An exhaustive algorithm for hip fracture treatment can be implemented. In our case, the algorithm both raised the rate of supervision and reduced the rate of reoperations, the latter saving many hospital bed-days

Introduction. In orthopaedics, clinical outcome assessment (COA) is still mostly performed by questionnaires which suffer from subjectivity, a ceiling effect and pain dominance. Real life activity monitoring (AM) holds the promise to become the new standard in COA with small light weight and easy to use accelerometers. More and more activities can be identified by algorithms based on accelerometry. The identification of stair climbing for instance is important to assess the participation of patients in normal life after an orthopaedic procedure. In this study we validated a custom made algorithm to distinguish normal gait, ascending and descending stairs on a step by step basis. Methods. A small, lightweight 3D-accelerometer taped to the lateral side of the affected (patients) or non-dominant (healthy subjects) upper leg served as the activity monitor. 13 Subjects (9 patients, 4 healthy) walked a few steps before descending a flight stairs (20 steps with a 180o turn in the middle), walked some steps more, turned around and ascended the same stairs. Templates (up, down and level) were obtained by averaging and stretching the vertical acceleration in the 4 healthy subjects. Classification parameters (low pass (0.4 Hz) horizontal (front-back) acceleration and the Euclidian distance between the vertical acceleration and each template) were obtained for each step. Accuracy is given by the percentage of correctly classified steps. Results. In total the subjects took 537 (41+/-8 mean+/-std) steps, 525 of which were correctly identified as step. 12 Steps were not detected, and 2 steps were incorrectly identified as step. Per subject the accuracy of the classification algorithm ranged from 57% to 97%. In only 2 subjects the accuracy was less than 75%, giving an overall accuracy of 85%. Discussion. In literature algorithms able to identify walking the stairs and normal walking have been reported with an accuracy in the range of 80–95%1,2. Our algorithm falls well within this range, and can be even further improved. The low accuracy in two subjects can be explained by the fact that the sensor was placed more to the front of the leg, which influences the low-pass horizontal acceleration. Using a combination of front-back and left-right acceleration could possibly solve this problem. In the future we are confident to identify also other activities and even distinguish different types of stair climbing (i.e. taking a step with each leg versus only taking steps with the unaffected leg and ‘dragging’ the second leg) and obtain more specific activity profiles to be used in clinical outcome assessment

Introduction. There is a need for a standardised guideline to assist in optimal decision-making in diabetics who have acquired an ankle fracture. Through a critical analysis of the literature, a diagnostic and management algorithm that incorporates a quantitative scoring system is proposed and presented for consideration. Methods. Publications were identified by conducting a comprehensive keyword search of Medline, EMBASE and CINAHL databases. Search terms included “diabetes,” “ankle,” and “fracture”. Articles published in the English language that were pertinent to the topic were included. Manual search of the references in these relevant papers were also completed to further identify publications for potential inclusion. Publications and conferences not published in the English language or not pertinent to the topic in the above databases were excluded. Duplicate results that occurred in different databases were truncated to a single result. Results. A total of 352 results were revealed using the above methods. Of these, 59 articles met our inclusion criteria. 293 articles met our exclusion criteria. A further 9 articles were included after reviewing the included articles and their respective references. From these results, we propose a detailed diagnostic algorithm that may provide a systematic approach to a diabetic patient who presents with acute ankle pain, swelling, warmth, and/or redness. If a fracture is noted on plain radiographs, a proposed management algorithm and scoring system can be used to assist in deciding whether to proceed with primary open reduction, internal fixation (ORIF) or primary arthrodesis/rigid fixation. This scoring system is based on factors acquired through history and examination. Major factors have been allocated a score of 2, which include: previous or coinciding history of Charcot arthropathy, peripheral neuropathy, insulin dependence with poor compliance, and a diabetic history of greater than 20 years. Minor factors have been allocated a score of 1, which include: age > 50, nephropathy, retinopathy, osteoporosis, vasculopathy, and presence of nutrition/diet deficiency. A score of greater than 7 suggests a primary limb-salvage arthrodesis/rigid fixation because of the likely poor outcome in a primary ORIF. A score of less than 7 suggests that an acceptable outcome will likely result with a primary ORIF. Discussion. Through the use of the AFDA algorithm and score, it will hopefully provide a standardised approach to diabetic ankle fractures and; a method of quantifying risks for both the patient and affected ankle joint, thus, allowing the surgeon to have confidence in achieving the best possible outcome. Although this score is based on a critical analysis of the current literature, further validation of both this algorithm and score is recommended. Once validated, the AFDA score in particular, can also potentially be used as a research tool for further follow-up and outcome studies on diabetic ankle fractures

Introduction. Short-segment posterior instrumentation for spine fractures is threatened by unacceptable failure rates. Two important design objectives of pedicle screws, bending and pullout strength, may conflict with each other. Hypothesis. Multiobjective optimization study with artificial neural network (ANN) algorithm and genetic algorithm (GA). Materials & Methods. Three-dimensional finite element (FE) methods were applied to investigate the optimal designs of pedicle screws with an outer diameter of 7 mm using a multiobjective approach for these two objectives. Based on the FE results on an L25 orthogonal array, two objective functions were developed by an ANN algorithm. Then, the trade-off solutions known as Pareto optima were explored by a GA. The optimal design was validated by mechanical tests. Results. The knee solutions of the Pareto fronts had simultaneous high bending and pullout strength ranging from 92 to 94 percent of their maxima. The corresponding range of the design parameters was 3.8 to 4.06 mm for inner diameter and 3.21 to 3.3 mm for pitch; 0 mm for beginning position of conical angle, 0.4 mm for proximal root radius, 5 degrees for proximal half angle, and 0.1 mm for thread width. The optimal design was well validated by mechanical tests, comparing with commercially available pedicle screws. Discussion & Conclusions. The optimal design of pedicle screws obtained could achieve an ideal with high mechanical performance in both bending and pullout tests

Introduction. Although a previous hip fracture is one of the strongest predictors for the next one this risk might be modified by other factors. The goal of this analysis was to compute a simple algorithm to assess the individual risk for a contralateral hip fracture. Materials and methods. The analysis is based on a nationwide population-based Danish cohort study of 84,360 patients experiencing a hip fracture followed-up for 5 years. We a priori defined a set of 17 candidate parameters potentially associated with early contralateral hip fracture. We bootstrapped a stepwise augmentation procedure 10 times and selected five parameters that entered the model in all bootstrapping cycles and computed the individual risk for a contralateral fracture within two, three, and five years after the first incidence. Results. 12,349 patients (14.6%) experienced a contralateral hip fracture within five years. The strength of association were: female gender (Odds Ratio 1.58), alcohol abuse 1.57, living in a single household 1.10, no prescription of bisphosphonates 1.64, and comorbidity and Charlson Score values less than 2 2.20, between 3 and 4 1.76, 5 and more, 1.46 against no comorbidity. The probability of experiencing a second fracture ranged from 3.4% to 25.9%. Discussion. Once this instrument is validated in other cohorts it provides a rational basis for prophylactic augmentation or more aggressive pharmaceutical treatment

Peri-prosthetic wound infections can complicate total knee arthroplasty (TKA) in 1–1.5% of cases and may require the input of a combined orthopaedic and plastic surgery team. Failure of optimal management can result in periprosthetic joint infection, arthrodesis or in severe cases limb amputation.

A retrospective 11-year review of TKA patients was undertaken in a single unit. Data was collected on a proforma and patient demographics were identified by case note analysis. Incidence of periprosthetic wound infections was recorded. A protocol to standardise treatment was subsequently developed following multidisciplinary input.

56 patients over 11 years developed periprosthetic wound infection. 33 patients were available for analysis. The male:female ratio 1:0.7 with a mean age of 70 years (range: 32–88 years). 5 (15%) developed superficial infections, 4 (12%) patients developed cellulitis requiring antibiotics, 14 (42%) with superficial wound dehiscence and 2 (6%) required washout of the prosthesis with long-term antibiotic therapy. 4 (12%) were managed without plastics involvement, one leading to arthrodesis and 4 (12%) had plastic surgical input, with one leading to arthrodesis. The mean time before plastic surgical review after initial suspicion of infection was 13 weeks.

The management of periprosthetic wound infections following TKA are variable and can require a multidiscplinary ortho-plastic approach. Early plastic surgical involvement in specific cases may improve outcome. Our proposed management protocol would facilitate in standardising the management of these complex patients.

Introduction

Segmental bone defect is a challenging problem. We report our experience of bone transport by hexapod external fixator in patients with segmental defects if the tibia.

Aims. The purpose of this study was to develop a convolutional neural network (CNN) for fracture detection, classification, and identification of greater tuberosity displacement ≥ 1 cm, neck-shaft angle (NSA) ≤ 100°, shaft translation, and articular fracture involvement, on plain radiographs. Methods. The CNN was trained and tested on radiographs sourced from 11 hospitals in Australia and externally validated on radiographs from the Netherlands. Each radiograph was paired with corresponding CT scans to serve as the reference standard based on dual independent evaluation by trained researchers and attending orthopaedic surgeons. Presence of a fracture, classification (non- to minimally displaced; two-part, multipart, and glenohumeral dislocation), and four characteristics were determined on 2D and 3D CT scans and subsequently allocated to each series of radiographs. Fracture characteristics included greater tuberosity displacement ≥ 1 cm, NSA ≤ 100°, shaft translation (0% to < 75%, 75% to 95%, > 95%), and the extent of articular involvement (0% to < 15%, 15% to 35%, or > 35%). Results. For detection and classification, the algorithm was trained on 1,709 radiographs (n = 803), tested on 567 radiographs (n = 244), and subsequently externally validated on 535 radiographs (n = 227). For characterization, healthy shoulders and glenohumeral dislocation were excluded. The overall accuracy for fracture detection was 94% (area under the receiver operating characteristic curve (AUC) = 0.98) and for classification 78% (AUC 0.68 to 0.93). Accuracy to detect greater tuberosity fracture displacement ≥ 1 cm was 35.0% (AUC 0.57). The CNN did not recognize NSAs ≤ 100° (AUC 0.42), nor fractures with ≥ 75% shaft translation (AUC 0.51 to 0.53), or with ≥ 15% articular involvement (AUC 0.48 to 0.49). For all objectives, the model’s performance on the external dataset showed similar accuracy levels. Conclusion. CNNs proficiently rule out proximal humerus fractures on plain radiographs. Despite rigorous training methodology based on CT imaging with multi-rater consensus to serve as the reference standard, artificial intelligence-driven classification is insufficient for clinical implementation. The CNN exhibited poor diagnostic ability to detect greater tuberosity displacement ≥ 1 cm and failed to identify NSAs ≤ 100°, shaft translations, or articular fractures. Cite this article: Bone Joint J 2024;106-B(11):1348–1360

Aims. The aim of this study was to determine the impact of hospital-level service characteristics on hip fracture outcomes and quality of care processes measures. Methods. This was a retrospective analysis of publicly available audit data obtained from the National Hip Fracture Database (NHFD) 2018 benchmark summary and Facilities Survey. Data extraction was performed using a dedicated proforma to identify relevant hospital-level care process and outcome variables for inclusion. The primary outcome measure was adjusted 30-day mortality rate. A random forest-based multivariate imputation by chained equation (MICE) algorithm was used for missing value imputation. Univariable analysis for each hospital level factor was performed using a combination of Tobit regression, Siegal non-parametric linear regression, and Mann-Whitney U test analyses, dependent on the data type. In all analyses, a p-value < 0.05 denoted statistical significance. Results. Analyses included 176 hospitals, with a median of 366 hip fracture cases per year (interquartile range (IQR) 280 to 457). Aggregated data from 66,578 patients were included. The only identified hospital-level variable associated with the primary outcome of 30-day mortality was hip fracture trial involvement (no trial involvement: median 6.3%; trial involvement: median 5.7%; p = 0.039). Significant key associations were also identified between prompt surgery and presence of dedicated hip fracture sessions; reduced acute length of stay and both a higher number of hip fracture cases per year and more dedicated hip fracture operating lists; Best Practice Tariff attainment and greater number of hip fracture cases per year, more dedicated hip fracture operating lists, presence of a dedicated hip fracture ward, and hip fracture trial involvement. Conclusion. Exploratory analyses have identified that improved outcomes in hip fracture may be associated with hospital-level service characteristics, such as hip fracture research trial involvement, larger hip fracture volumes, and the use of theatre lists dedicated to hip fracture surgery. Further research using patient level data is warranted to corroborate these findings. Cite this article: Bone Joint J 2021;103-B(10):1627–1632

Introduction. In orthopaedics, clinical outcome assessment (COA) is mostly performed by questionnaires which suffer from subjectivity, a ceiling effect and pain dominance. Real life activity monitoring (AM) can objectively assess function and becomes now feasible as technology has become smaller, lighter, cheaper and easier to use. In this study we validated a custom made algorithm based on accelerometry using different orthopaedic patients with the aim to use AM in orthopaedic COA. Methods. A small, lightweight 3D-accelerometer taped to the lateral side of the affected upper leg served as the activity monitor. AM algorithms were programmed in Matlab to classify standing, sitting, and walking. For validation a common protocol was used; subjects were asked to perform several tasks for 5 or 10 seconds in a fixed order. An observer noted the starting time of each task using a stopwatch. Accuracy was calculated for the number of bouts per activity as well as total time per activity. 10 Subjects were chosen with different pathologies (e.g. post total knee/hip arthroplasty, osteoarthritis) since the difference in movement dynamics in each pathology poses a challenge to the algorithm. Results. In total the subjects performed 267 activities (99 standing, 80 sitting, 88 walking), 258 of which (99, 73, 87 resp.) were classified correctly by the algorithm, corresponding to a sensitivity of 97%. Sensor misplacement in 1 subject caused all missed instances in sitting, and exclusion of this subject increased sensitivity to 99.9%. 5 Instances of standing were incorrectly added by the algorithm, giving a specificity of 95% for standing. In total 80 sit-stand, and 78 stand-sit transitions were performed. Subjects were standing for 792 seconds, sitting for 764 s, and walking for 905 s. The algorithm found a total duration of 739, 583 and 1056 seconds for those activities respectively, and 83 seconds of lying (misclassification of sitting). Discussion. Sensor placement is an important factor to obtain reliable results. Even so sensitivity and specificity are comparable to values found in literature [85–99%]. The added instances of standing occurred when a subject did not immediately sit after a period of walking. It is doubtful if these instances should be considered false positives. The main difference in duration is also found in sitting, which is caused by the missed instances previously described, in combination with the fact that the duration of transitions are added to the walking period in the algorithm, whereas it is divided over sitting and walking by the observer. This corresponds to a difference of less than one second per transition. The algorithm produces reliable results when challenged with different movement patterns common with orthpaedic pathologies. The device may be used as as AM in objective assessment of clinical outcome after orthopaedic procedures

Aims

To compare the cost-effectiveness of high-dose, dual-antibiotic cement versus single-antibiotic cement for the treatment of displaced intracapsular hip fractures in older adults.

Aims

This study aimed to describe practice variation in the use of total hip arthroplasty (THA) for older patients with femoral neck fracture and to determine the association between patient, surgeon, and institution factors and treatment with THA.

Aims

Though most humeral shaft fractures heal nonoperatively, up to one-third may lead to nonunion with inferior outcomes. The Radiographic Union Score for HUmeral Fractures (RUSHU) was created to identify high-risk patients for nonunion. Our study evaluated the RUSHU’s prognostic performance at six and 12 weeks in discriminating nonunion within a significantly larger cohort than before.

Aims

Several previously identified patient-, injury-, and treatment-related factors are associated with the development of nonunion in distal femur fractures. However, the predictive value of these factors is not well defined. We aimed to assess the predictive ability of previously identified risk factors in the development of nonunion leading to secondary surgery in distal femur fractures.

Aims

The aim of this study was to examine perioperative blood transfusion practice, and associations with clinical outcomes, in a national cohort of hip fracture patients.

Aims

Patients with A1 and A2 trochanteric hip fractures represent a substantial proportion of trauma caseload, and national guidelines recommend that sliding hip screws (SHS) should be used for these injuries. Despite this, intramedullary nails (IMNs) are routinely implanted in many hospitals, at extra cost and with unproven patient outcome benefit. We have used data from the National Hip Fracture Database (NHFD) to examine the use of SHS and IMN for A1 and A2 hip fractures at a national level, and to define the cost implications of management decisions that run counter to national guidelines.

We describe the impact of a targeted performance improvement programme and the associated performance improvement interventions, on mortality rates, error rates and process of care for haemodynamically unstable patients with pelvic fractures. Clinical care and performance improvement data for 185 adult patients with exsanguinating pelvic trauma presenting to a United Kingdom Major Trauma Centre between January 2007 and January 2011 were analysed with univariate and multivariate regression and compared with National data. In total 62 patients (34%) died from their injuries and opportunities for improved care were identified in one third of deaths. Three major interventions were introduced during the study period in response to the findings. These were a massive haemorrhage protocol, a decision-making algorithm and employment of specialist pelvic orthopaedic surgeons. Interventions which improved performance were associated with an annual reduction in mortality (odds ratio 0.64 (95% confidence interval (CI) 0.44 to 0.93), p = 0.02), a reduction in error rates (p = 0.024) and significant improvements in the targeted processes of care. Exsanguinating patients with pelvic trauma are complex to manage and are associated with high mortality rates; implementation of a targeted performance improvement programme achieved sustained improvements in mortality, error rates and trauma care in this group of severely injured patients. Cite this article: Bone Joint J 2014;96-B:1090–7

Aims

Deep surgical site infection (SSI) is common after lower limb fracture. We compared the diagnosis of deep SSI using alternative methods of data collection and examined the agreement of clinical photography and in-person clinical assessment by the Centers for Disease Control and Prevention (CDC) criteria after lower limb fracture surgery.

Aims

The aim of this study was to assess the association of mortality and reoperation when comparing cemented and uncemented hemiarthroplasty (HA) in hip fracture patients aged over 65 years.

Necrotising Fasciitis is a life threatening rapidly progressing bacterial infection of the skin requiring prompt diagnosis and treatment. Optimum care warrants a combination of antibiotics, surgical debridement and intensive care support. All cases of Necrotising Fasciitis over 10 years in the North East of Scotland were reviewed to investigate trends and learn lessons to improve patient care, with the ultimate aim of developing and implementing new treatment algorithms. All cases from August 2006-February 2016 were reviewed using a combination of paper based and electronic hospital records. Data including observations, investigations, operative interventions, microbiology and clinical outcomes was reviewed and analysed with pan-specialty input from Microbiology, Infectious Disease, Trauma & Orthopaedics, Plastic Surgery and Intensive Care teams. 36 cases were identified, including 9 intravenous drug abusers. The mean LRINEC Score was 7. Patients were commonly haemodynamically stable upon admission, but deteriorated rapidly. 18/31 of cases were polymicrobial. Streptococcus Pyogenes was the most common organism in monomicrobial cases. 29/36 patients were discharged, 6 patients died acutely, giving an acute mortality rate of 17%. In total 6 amputations or disarticulations were performed from a total of 82 operations carried out on this group, with radical debridement the most common primary operation. The mean time to theatre was 3.54 hours. A grossly elevated admission respiratory rate (50 resp/min) was associated with increased mortality. Necrotising fasciitis presents subtly, but carries significant morbidity and mortality. A high index suspicion allows timely intervention. We strongly believe that a pan-specialty approach is the cornerstone for good outcomes