The last decade has seen a rise in the use of the gamma nail for managing inter-trochanteric and subtrochanteric hip fractures. Patients with multiple co-morbidities are under high anaesthetic risk of mortality and are usually not suitable for general or regional anaesthesia. However, there can be a strong case for fixing these fractures despite these risks. Apart from aiming to return patients to their pre-morbid mobility, other advantages include pain relief and reducing the complications of being bed bound (e.g. pressure ulcers, psychosocial factors). While operative use of local anaesthesia and sedation has been documented for insertion of extra-medullary femoral implants such as the sliding hip screw, currently no literature is present for the insertion of the gamma nail. We studied intra-operative and post-operative outcomes of three patients aged between 64 and 83 with right inter-trochanteric hip fractures and American Society of Anesthesiologists (ASA) scores of 4 or more. Consent for each case was obtained after discussion with the patient and family, or conducted with the patient's best interests in mind. All patients received a short unlocked gamma nail, and were operated on within 24 hours of admission. Each patient underwent local injections of Bupivacaine or Lignocaine or both, with Epinephrine, and with one patient receiving nerve block of the fascia iliaca. Each patient received a combination of sedatives under the discretion of the anaesthetist including Midazolam, Ketamine, Propofol, Fentanyl, and/or Haloperidol. Operating time ranged from 30–90 minutes. Patients were managed post-operatively with analgesia based on the WHO pain ladder and physiotherapy. Our results showed no intra-operative complications in any of the cases. All patients noted improvement in their pain and comfort post-operatively without complications of the operation site. Two patients achieved their pre-morbid level of mobility after undergoing physiotherapy and were subsequently discharged from the orthopaedic team. One patient with ongoing pre-operative medical complications died 5 days after the operation. This study provides a glimpse into the use of local anaesthetic and sedation on high operative risk patients, and this may be a viable alternative to extra-medullary implants or non-operation. Further research is needed to quantify the risks and benefits of operating within this patient group

Aims

We performed a retrospective, comparative study of elderly patients with an increased risk from anaesthesia who had undergone either anterior screw fixation (ASF) or halo vest immobilisation (HVI) for a type II odontoid fracture.

Aim. Smoking is known to impair wound healing and to increase the risk of peri-operative adverse events and is associated with orthopaedic infection and fracture non-union. Understanding the magnitude of the causal effect on orthopaedic infection recurrence may improve pre-operative patient counselling. Methods. Four prospectively-collected datasets including 1173 participants treated in European centres between 2003 and 2021, followed up to 12 months after surgery for clinically diagnosed orthopaedic infections, were included in logistic regression modelling with Inverse Probability of Treatment Weighting for current smoking status [1–3]. Host factors including age, gender and ASA score were included as potential confounding variables, interacting through surgical treatment as a collider variable in a pre-specified structural causal model informed by clinical experience. The definition of infection recurrence was identical and ascertained separately from baseline factors in three contributing cohorts. A subset of 669 participants with positive histology, microbiology or a sinus at the time of surgery, were analysed separately. Results. Participants were 64% male, with a median age of 60 years (range 18–95); 16% of participants experienced treatment failure by 12 months. 1171 of 1173 participants had current smoking status recorded. As expected for the European population, current smoking was less frequent in older participants (Table 1). There was no baseline association between Charlson score or ASA score and smoking status (p=0.9, p=1, Chi squared test). The estimated adjusted odds ratio for treatment failure at 12 months, resulting from current smoking at the time of surgery, was 1.37 for all participants (95% CI 0.75 to 2.50) and 1.53 for participants with recorded confirmatory criteria (95% CI 1.14 to 6.37). Conclusions. Smoking contributes to infection recurrence, particularly in people with unequivocal evidence of osteomyelitis or PJI. People awaiting surgery for orthopaedic infection should be supported to cease smoking, not only to reduce anaesthetic risk, but to improve treatment outcomes. Limitations of this study include unmeasured socioeconomic confounding and social desirability bias resulting in uncertainty in true smoking status, resulting in underestimated effect size

Introduction and purpose: Osteoporotic hip fractures are a major cause of hospital morbidity and mortality in geriatric patients. Our purpose was to study hospital mortality due to osteoporotic hip fractures in persons over 50 in our hospital and evaluate the prognostic factors for mortality. Materials and methods: We carried out a prospective evaluation of all patients with osteoporotic hip fractures admitted to our hospital between March and September 2004. We emphasised the possible predictive factors for hospital mortality, such as individual background, clinical situation, cognitive aspects, functional and social situation, treatment used and complications. We excluded patients with high-energy or pathological fractures and those who did not want to sign the informed consent form for inclusion in the study. The data were analysed with SPSS statistical software v11.0. Results: In the six-month period mentioned above, 357 patients were admitted for osteoporotic hip fracture. The female/male ratio was 2.9:1. 37.6% were over 85 and 28.1% had been institutionalised prior to admission. 27 patients died while in hospital (7.6%), with a similar distribution between preoperative and postoperative mortality. The most common causes of death were related to decompensation of the patient’s baseline pathology, mainly of cardiorespiratory origin. Multivariate analysis showed significant prognostic factors independent of hospital mortality (p< 0.05): male sex (RR=4.3), age over 80 (RR=2.9), prior institutionalisation in a care home, the presence of confusional syndrome, low haemoglobin on admission and anaesthetic risk above III. Conclusions: Hospital mortality was found to be high in cases of hip fracture. This was similar to previous studies carried out in our hospital and others. The prognostic factors for mortality were, above all, those that could not be changed (age, sex, anaesthetic risk, institutionalisation). Patients over 85, men, those coming from a care home and those with high anaesthetic risk have a greater risk of dying while in hospital. We should also be attentive to haemoglobin on admission and the presence of acute confusional syndrome

The February 2015 Research Roundup360 looks at: Markers of post-traumatic ankle arthritis; Mangoes, trees and Solomon Islanders; Corticosteroid injection and ulnar neuropathy; Moral decision-making: the secret skill?; Biomechanical studies under the spotlight; Anaesthetic risk and hip replacement

Deep vein thrombosis (DVT) in shoulder operations is rare although a few case reports exist. No definite guidelines exist and therefore it is difficult for the surgeon to decide on thromboprophylaxis. We prospectively evaluated the incidence of DVT following arthroscopic shoulder sub acromial decompression in 72 patients after obtaining local ethics committee approval. Patients with previous history of DVT and those on anticoagulants were excluded from the study. Pre and post-operative Doppler scans on 4 limbs were performed by a single consultant radiologist at an average of 3 weeks. All operations were performed by a single surgeon under GA in beach chair position as a day case procedure on standard lines. Postoperatively the shoulder was immobilised in a sling for comfort and physiotherapy was supervised by a qualified therapist. No patient received any DVT prophylaxis. The average age of 54.6 years, 47 were classified as ASA 1, 15 as ASA 2 and 10 ASA 3.58 patients had additional interscalene nerve blocks for pain relief. The average operating time was 43 mins. Additional procedures included excision of lateral clavicle in 32, glenoid labral and rotator cuff debridement in 12 and 14 patients. There were no DVTs on Doppler scans. Shoulder arthroscopic sub acromial decompression procedures do not carry a risk of DVT and routine thromboprohylaxis is not required even in higher anaesthetic risk patients

Introduction. Femoral neck fractures are an increasingly common injury in the elderly. Frequently these patients present taking Clopidogrel, an irreversible inhibitor of platelet aggregation. Although this is associated with an increased risk of intra-operative bleeding and also an increased risk of spinal haematoma where regional anaesthesia is employed, the recent SIGN (Scottish Intercollegiate Guidance Network) guidelines recommend that surgery should not be delayed. Methods. We conducted a retrospective review of consecutive patients admitted with femoral neck fractures between April 2008 and October 2009. Patients on Clopidogrel were identified and data including ASA grade, time to operation, medical co-morbidities, and post-admission complications were recorded. Comparative information from the National Hip Fracture Database was used. Results. 405 patients were included. 27 patients were taking Clopidogrel on admission and they were mainly ASA 3 or 4. Mean time to theatre was 8 days. Post-admission medical complications occurred in 7 patients (25.9%). A further 4 patients (14.8%) died, 3 of them postoperatively. From the study population a control group of 72 ASA 3 and 4 patients was further studied. The mean time to operation was 2.3 days. Post-admission medical complications occurred in 13 patients (18%) and 8 patients (11%) died postoperatively. In 2009 the national mean time to operation was 2.19 days with an associated mortality rate of 8.67%. Discussion and Conclusion. Patients receiving Clopidogrel have complex medical co-morbidities and a higher anaesthetic risk. Delaying operative management might be contributing to the increased rate of mortality and morbidity. In accordance with the SIGN guidelines we recommend early operative intervention in these high risk patients

The purpose of this study was to evaluate the outcome of internal fixation for undisplaced intracapsular fracture neck of femur in elderly group of patients with a view to evaluate the incidence of definitive procedure at a later date. The method used for evaluation was retrospective study of 46 consecutive cases within one year, operated for Garden 1 or 2 type of fractures, who were followed up for upto 2 years. Postoperative complications, the need for further intervention and relationship with age and preoperative ASA grade was assessed. Results of the study were quite interesting. 74% patients were above the age of 60 years. 60% of them (30 out of total 46) stayed in the wards for more then one week, due to medical problems. 35% (16 out of total 46) required further intervention in form of hemi-arthroplasty or total joint replacement, either due to implant failure or avascular necrosis. 63% of those who required further intervention 10 out of 16) were ASA grade 3 or above. Conclusion of the study was that although internal fixation is a relatively small procedure, the complication rate, requiring further intervention was higher then anticipated. There is a role of primary definitive procedure in certain number of cases, specially those having higher anaesthetic risk i.e. ASA grade 3 or above

We obtained approval from the local research and ethics committee and prospectively evaluated the incidence of Deep vein thrombosis (DVT) in arthroscopic shoulder sub acromial decompression in 72 patients. All patients were assessed clinically for DVT risks as per the established guidelines. Patients with previous history of DVT, those on anticoagulants and those positive for DVT on pre op scans were excluded from the study. All patients had doppler scans on 4 limbs performed by a single consultant radiologist at an average of 4 weeks pre and post operative period. All operations were performed by a single surgeon under GA in beach chair position with routine precautions for DVT, as a day case procedure. Arthroscopy and additional procedures were performed on standard lines. Postoperatively the shoulder was immobilised in a sling for comfort and physiotherapy was supervised by a qualified therapist. Demographic data, co-morbidities, patient position, ASA risk, nerve blocks, surgery duration, medications, intra operative findings, were documented. No patient received any DVT prophylaxis. All patients were available for followup and clinical and doppler findings were documented at an average 4 week period. 3 patients had bilateral procedures. There were 38 female and 34 male patients with an average age of 54.6 years. 47 were classified as ASA1, 15 as ASA2 and 10 ASA 3. Common co morbidities included hypertension, diabetes, acid peptic disease in 34 patients. 37 patients had additional interscalene nerve blocks for pain relief. The average operating time was 52 mins. Additional procedures included excision of lateral clavicle in 32, glenoid labral and rotator cuff debridement in 12 and 14 patients. There were no DVT's on all doppler scans. Shoulder arthroscopic sub acromial decompression procedures do not carry a risk of DVT and routine thromboprohylaxis is not required even in higher anaesthetic risk patients

Introduction. Elective Orthopaedics has been targeted by the UK Department of Health as a maximum six-month waiting time for operations could not be met. The National Orthopaedic Project was initiated as a consequence and Independent Sector Treatment Centres (ISTCs) and well established private hospitals were utilised to treat NHS long wait patients. Materials and methods. We audited the primary total hip replacements performed in our hospital in 1998 and 2003 to compare the differences in the patient characteristics in particular age, length of stay and ASA grade. Results. The number of hip replacements increased to 308 in year 2003 from 194 in year 1998. Whilst the number of ASA I patients was the same, the ASA II, III and IV increased by 40%, 260% and 266% respectively. The average length of stay decreased from 14.3 to 11.9 days which was statistically significant, in spite of increased numbers of ASA II - IV patients. Discussion. The NHS hospitals are treating an increasing number of patients who have a higher anaesthetic risk and stay longer in the hospital in the post-operative period. The case mix for primary total hip replacements in large tertiary referral hospitals has changed due to altered patient flow due to cherry picking of NHS waiting lists by the ISTCs. NHS hospitals should be appropriately remunerated for dealing with complex cases. On average based on our data, ASA III patients stay 3 days longer than ASA I (ASA IV - 5 days). The extra cost incurred is £221 (£433) / day x 3 extra days = £ 663 (£ 1329) / case. According to the 2nd annual NJR report, 4,617 ASA III patients were operated in NHS hospitals and the extra cost incurred towards their length of stay would be £3.06 million (£6.1 million)

Introduction: Elective Orthopaedics has been targeted by the department of health in the U.K. as a maximum six-month waiting time for operations could not be met. National Orthopaedic project was initiated as a consequence and Independent Sector Treatment Centres (ISTC) and well established private hospitals were utilised to treat NHS long wait patients. Materials and Methods: We audited the primary total hip replacements performed in our hospital in 1998 and 2003 to compare the differences in the patient characteristics in particular age, length of stay and ASA grade. Results: The number of hip replacements increased to 308 in year 2003 from 194 in year 1998. Whilst, the number of ASA I patients were the same, the ASA II. III, IV increased by 40%, 260%, 266% respectively. The average length of stay decreased from 14.3 to 11.9 days which was statistically significant, in spite of increased numbers of ASA II – IV patients. Discussion: The NHS hospitals are treating increasing number of patients who have a higher anaesthetic risk and are likely to stay longer in the hospital in the post-operative period. The case mix for primary total hip replacements in large tertiary referral hospitals have changed due to altered patient flow due to cherry picking of NHS waiting lists by the ISTC. NHS hospitals should be appropriately remunerated for dealing with complex cases and for managing complications referred by ISTC hospitals. In fact, the National joint registry’s 2. nd. annual report confirms that 40% of primary total hip replacements operated in ISTC’s were ASA I while only 25% of primary total hip replacements operated in NHS hospitals were ASA I. None of the ISTC’s performed complex primary THRs

Purpose: To evaluate the indications, outcome, risk factors and complications of transpedicular osteotomy (TPO) in revision scoliosis surgery. Methods: We evaluated patients undergoing TPO for revision scoliosis surgery at our institution between 1989 and 2004 with a minimum follow up of 18 months. Demographic data, anaesthetic risk factors, peri-operative data and complications were recorded. Radiographs pre-operatively, post-operatively and at last follow up recorded sagittal balance, coronal balance, lumbar lordosis and pelvic parameters. Functional outcome was measured using the Whitecloud score. Results: 21 patients (24 TPO’s) mean age 48.7 years with mean follow up 4.4 years fulfilled criteria for study. All cases had fixed sagittal imbalance pre-operatively. Mean operative time was 4.6 hours and mean transfusion requirement was 2.3. units. A significant improvement (p< 0.03) in sagittal imbalance was gained (although in 3 cases of pseudarthroses this was partially lost) and the post-operative lumbar lordosis correlated closely significantly pelvic incidence (p< 0.03). Functional outcome was good/excellent in 67% cases. We report 28 complications. 22 early included 4 dural tears, cardiac decompensation with reduction, 5 neurological deficits including a parpaplegia secondary to haematoma which was evacuated and the patient made a good recovery at 6 months, 2 UTIs, IVI infection, superficial wound infection and extension of metalwork due to early proximal decompensation. Late complications included infection (8 years), removal of prominent metalwork, radiculopathy due to screw (6 months) and 3 pseudarthroses. There was no statistically significant correlation of complication with weight, ASA grade or smoking. Conclusion: TPO in revision scoliosis is an effective method of correcting both coronal and sagittal imbalance but is not without complication, although good functional outcome is achieved in most patients. It is important to consider pelvic parameters pre-operatively to plan the level and magnitude of TPO required

Aims: To determine the feasibility and short-term outcome after Total Hip Arthroplasty through a limited anterior approach. Methods: Done between April 2003 and August 2004, 100 patients (102 hips) requiring primary total hip arthroplasty comprise this study. A modification of the Smith-Peterson anterior approach developed by Robert Judet was used requiring a special fracture table (Pro-Fx, OSI) but no unique surgical instruments. A single incision was used; the natural interval between the sartorius and rectus muscles medially and the tensor muscle laterally was developed. SL-Plus stems and Plus-MPF or Encore cups were used in all cases. This series is entirely unselected: no patients were excluded because of size or body habitus. One third of the patients had a Body Mass Index greater than 30 (obese); the maximum BMI was 45.6. One third had type C bone and nearly one tenth were category 3 anesthetic risks. Average age was 72 (range 39 to 90). A naive definition of “minimally invasive” is met: the average incision length was 9.5 centimeters (range 6.5 to 13). Result: Time for the surgical procedure reduced from three and one half hours for the first arthroplasty to 70 minutes between the 15th and 20th operation. Previously, hospital stay averaged over 5 days using a conventional posterior approach; average stay with the “minimal” approach was less than 3 days. Only 20% of these patients required an intermediate care facility prior to returning home. There have been three complications requiring readmission: 1 dislocation, 1 unstable acetabulum, and 1 superficial wound breakdown. There has been a total of 3 dislocations-all within 4 days of surgery, none recurrent. One DVT has been detected. Conclusions: The early experience, “learning curve” and technical complications of the modified Smith-Peterson anterior approach are emphasized. Given the consistently reported 95% to 98% success rate of conventional hip arthroplasty it is imperative to make any change with foresight and then to document the consequence of that change. Surgical technique should not absolutely dictate implant choice. This report sheds light on the very early result of a change only to the surgical approach to total hip arthroplasty

Aims: To assess whether patients undergoing one or two level open decompression of their lumbar spinal stenosis could have an interspinous device inserted with equal or less risk of complications and whether patient satisfaction is improved. Background: The reported incidence of lumbar spinal stenosis [LSS] varies [1.7% to 8%], as do the results of open surgical decompression. Implanting interspinous devices [ID] to relieve symptoms of LSS is a newer concept which has good short term results. Patients: Data was collected from 48 consecutive patients undergoing one or two level decompressions for symptoms of lumbar spinal stenosis from February 2008 to March 2009. Methods: Retrospective case note analysis of clinic letters, operation notes and inpatient stays was carried out. Two types of interspinous device (BacJac and X-stop) were used and the results have been collated. Results: 29 open decompressions [22 one level, 7 two level] were performed compared to 19 interspinous device insertions [7 one level, 9 two level]. Surgery was performed for patients with leg pain although 27 patients had concomitant back pain. The average age of the patients for open decompression (63yrs +/− 11) compared to interspinous device (63yrs +/− 9) was equal. Male to female ratio for Open Vs ID [1.4:1 Vs 1.1:1] did not differ significantly (p = 0.39). The ASA grades were higher for the interspinous device group with an average of 2.5 compared to 2.1 in the open group. The length of anaesthetic was on average shorter for the interspinous devices, which included a higher proportion of 2 level decompressions. The average length of stay on average was identical at 1.3 days, complications were similar [5% Vs 7%] with patient satisfaction higher [81% Vs 68%], although statistically insignificant [p=0.79]. Conclusion: There are certain criteria advised by the American Academy of Orthopaedic Surgeons to aid in selection of suitable patients for interspinous device insertion. 10 of the 29 patients for open decompression fitted these criteria. Interspinous device insertion is a less invasive procedure and can be carried out on patients with a higher anaesthetic risk, even being performed under sedation. It should be considered for patients with symptoms of LSS instead of open decompression as there is no effect on length of stay or complication rate and there is a trend toward a decrease in anaesthetic time with improved patient satisfaction in the short term

Introduction Over 250 patients older than 50 years with fractured neck of femur (NOF) are treated annually at The Canberra Hospital (TCH). Our aim was to improve patient outcomes and reduce length of stay by developing a protocol driven approach to management of patients with NOF fractures, particularly focusing on efficient peri-operative assessment and management of fluid and electrolyte status. Methods A prospective study of all patients over 50 years, admitted with a diagnosis of fractured neck of femur was carried out at TCH for a 12 month period. Baseline data was collected for a period of six months. We measured clinical factors including; time to theatre, pre-operative fluid resuscitation, length of stay and morbidity. A protocol was then introduced according to agreed best practice dealing with the issues identified in baseline data. Education of medical and nursing staff followed in the major treating areas: Emergency Department and orthopaedics ward. Following this a further six months data was collected to assess the effectiveness of the intervention. Results Over the 12 month period prior to this study, the length of stay following fractured NOF at TCH was 15.39 days compared to the benchmark of 12.94 days. In the initial six month period 116 patients were admitted to the study. Baseline data demonstrated: average length of stay 12.75 days (from ED to discharge), average time to theatre 35 hours, variable fluid resuscitation for the first 24 hours averaging 1668.4 mls (range: 0 to 4000 mls). The in-hospital death rate in this patient group was 9.5%. In the second six month period, following protocol implementation, improvements were noted to be greatest in fluid resuscitation for the first 24 hours, averaging 3000 mls. Smaller improvements were seen in time to theatre, averaging 34 hours. The mortality rate and length of stay were not significantly different probably due to the higher anaesthetic risk score of the second cohort (p< 0.05). Conclusions A program of outcomes assessment and evaluation in its first phase improved initial management of these patients and reduced length of stay. Further work is necessary to achieve timely assessment and early surgical intervention. Reducing the in-hospital death rate remains a problematic and complex issue

The June 2024 Knee Roundup³⁶⁰ looks at: The estimated lifetime risk of revision after primary knee arthroplasty influenced by age, sex, and indication; Should high-risk patients seek out care from high-volume surgeons?; Stability and fracture rates in medial unicondylar knee arthroplasties; Rethinking antibiotic prophylaxis for dental procedures post-arthroplasty; Evaluating DAIR: a viable alternative for acute periprosthetic joint infection; The characteristics and predictors of mortality in periprosthetic fractures around the knee; Patient health-related quality of life deteriorates significantly while waiting six to 12 months for total hip or knee arthroplasty; The importance of looking for diversity in knee implants.

Aims

Clinical management of open fractures is challenging and frequently requires complex reconstruction procedures. The Gustilo-Anderson classification lacks uniform interpretation, has poor interobserver reliability, and fails to account for injuries to musculotendinous units and bone. The Ganga Hospital Open Injury Severity Score (GHOISS) was designed to address these concerns. The major aim of this review was to ascertain the evidence available on accuracy of the GHOISS in predicting successful limb salvage in patients with mangled limbs.

We have compared the cost:benefit ratio of the new type of non invasive extendable prostheses with the old type which required lengthening under general anaesthetic with an invasive procedure. Over the past four years we have inserted 27 non invasive endoprostheses (cost £14,000). Two have failed to lengthen due to problems with the inbuilt motor. So far there have been no infections, no loosenings and no patient has required revision. The lengthenings are painless and take half an hour. In the past 25 years we inserted 175 extendable endoprostheses (cost £7,000). All lengthenings were performed under a general anaesthetic. The risk of infection was initially 20% at ten years but had decreased to 8%. Pain and stiffness arose in about 10% requiring physiotherapy or occasionally manipulation under anaesthetic. Assuming the following costs (current NHS cost) are accurate and appropriate, then the non invasive extendable prosthesis becomes cost effective when Cost EPR < Cost old EPR + (Additional risk physio(P) x cost) + (additional cost x number of lengthenings (L)) + (additional cost of revision for infection x risk of infection (R)). 14000 < 7000 + (300 x P) + (1500 x L) + (20000 x R). Assuming a 10% need for physiotherapy, four lengthenings and a 10% risk of infection gives: 14000 < 7000 + (30) +(6000) + (2000) = 15030. Given the high complication rate of the old type of extendable procedure and assuming there are few if any with the non invasive type, then the non-invasive endoprostheses becomes cost effective if more than three lengthenings are required. They are certainly more popular with parents and children alike!

Aims

This study sought to compare the rate of deep surgical site infection (SSI), as measured by the Centers for Disease Control and Prevention (CDC) definition, after surgery for a fracture of the hip between patients treated with standard dressings and those treated with incisional negative pressure wound therapy (iNPWT). Secondary objectives included determining the rate of recruitment and willingness to participate in the trial.