Introduction. Ankle fractures in the elderly have been increasing with an ageing but active population and bring with them specific challenges. Medical co-morbidities, a poor soft tissue envelope and a requirement for early mobilisation to prevent morbidity and mortality, all create potential pitfalls to successful treatment. As a result, different techniques have been employed to try and improve outcomes. Total contact casting, both standard and enhanced open reduction internal fixation, external fixation and most recently tibiotalocalcaneal (TTC) nailing have all been proposed as suitable treatment modalities. Over the past five years popular literature has begun to herald TTC nailing as an appropriate and contemporary solution to the complex problem of high-risk ankle fragility fractures. We sought to assess whether, within our patient cohort, the outcomes seen supported the statement that TTC has equal outcomes to more traditional open reduction internal fixation (ORIF) when used to treat the high-risk ankle fragility fracture. Materials & Methods. Results of ORIF versus TTC nailing without joint preparation for treatment of fragility ankle fractures were evaluated via retrospective cohort study of 64 patients with high-risk fragility ankle fractures without our trauma centre. We aimed to assess whether results within our unit were equal to those seen within other published studies. Patients were matched 1:1 based on gender, age, Charlson Comorbidity Index (CCI) and ASA score. Patient demographics, AO/OTA fracture classification, intra-operative and post-operative complications, discharge destination, union rates, FADI scores and patient mobility were recorded. Results. There were 32 patients within each arm. Mean age was 78.4 (TTC) and 78.3 (ORIF). The CCI was 5.9 in each group respectively with mean ASA 2.9 (TTC) and 2.8 (ORIF). There were two open fractures within each group. Median follow up duration was 26 months. Time to theatre from injury was 8.0 days (TTC) versus 3.3 days (ORIF). There was no statistically significant difference in 30-day, one year or overall mortality at final follow up. Kaplan-Meier survivorship analysis did however demonstrate that of those patients who died post-operatively the mean time to mortality was significantly shorter in those treated with TTC nailing versus ORIF (20.3 months versus 38.2 months, p=0.013). There was no statistical difference in the overall complication rate between the two groups (46.9% versus 25%, p=0.12). The re-operation rate was twice as high in patients treated with TTC nailing however this was not statistically significant. There was no statistical difference in the FADI scores at final follow up, 72.1±12.9 (TTC) versus 67.9±13.9 (ORIF) nor post-operative mobility status. Conclusions. Within our study TTC nailing with an unprepared joint demonstrated broadly equivalent results to ORIF in the management of high-risk ankle fragility fractures; this replicates findings of previous studies. We did however observe that mean survival was significantly shorter in the TTC group than those treated with ORIF. We believe this may have been contributed to by a delay to theatre due to TTC stabilisation being treated as a sub-specialist operation in our unit at the time. We propose that both TTC and ORIF are satisfactory techniques to stabilise the frail ankle fracture however, similarly to the other fragility fractures, the priority should be on an emergent operation in a timely fashion in order to minimise the associated morbidity and mortality. Further randomised control studies are needed within the area to establish definitive results and a working consensus

Management of acetabular fractures in the elderly population remains somewhat controversial in regards to when to consider is open reduction internal fixation (ORIF) versus acute primary total hip. study aims to (1) describe outcome of this complex problem and investigate predictors of successful outcome. This retrospective study analyzes all acetabular fractures in patients over the age of 60, managed by ORIF at a tertiary trauma care centre between 2007 and 2018 with a minimum follow up of one year. Of the 117 patients reviewed, 85 patients undergoing ORIF for treatment of their acetabular fracture were included in the analysis. The remainder were excluded based management option including acute ORIF with THA (n=10), two-stage ORIF (n=2), external fixator only (n=1), acute THA (n=1), and conservative management (n=1). The remainder were excluded based on inaccessible medical records (n=6), mislabelled diagnosis (n=6), associated femoral injuries (n=4), acetabular fracture following hemiarthroplasty (n=1). The mean age of the cohort is 70±7 years old with 74% (n=62) of patients being male. Data collected included: demographics, mechanism of injury, Charlson Comorbidity Index (CCI), ASA Grade, smoking status and reoperations. Pre-Operative Radiographs were analyzed to determine the Judet and Letournel fracture pattern, presence of comminution and posterior wall marginal impaction. Postoperative radiographs were used to determine Matta Grade of Reduction. Outcome measures included morbidity-, mortality- rates, joint survival, radiographic evidence of osteoarthritis and patient reported outcome measures (PROMs) using the Oxford Hip Score (OHS) at follow-up. A poor outcome in ORIF was defined as one of the following: 1) conversion to THA or 2) the presence of radiographic OA, combined with an OHS less than 34 (findings consistent with a hip that would benefit from a hip replacement). The data was analyzed step-wise to create a regression model predictive of outcome following ORIF. Following ORIF, 31% (n=26) of the cohort had anatomic reduction, while 64% (n=54) had imperfect or poor reduction. 4 patients did not have adequate postoperative radiographs to assess the reduction. 31 of 84 patients undergoing ORIF had a complication of which 22.6% (n=19) required reoperation. The most common reason being conversion to THA (n=14), which occurred an average of 1.6±1.9 years post-ORIF. The remainder required reoperation for infection (n=5). Including those converted to THA, 43% (n=36) developed radiographic OA following acetabular fracture management. The mean OHS in patients undergoing ORIF was 36 ± 10; 13(16%) had an OHS less than 34. The results of the logistic regression demonstrate that Matta grade of reduction (p=0.017), to be predictive of a poor outcome in acetabular fracture management. With non-anatomic alignment following fixation, patients had a 3 times greater risk of a poor outcome. No other variables were found to be predictive of ORIF outcome. The ability to achieve anatomic reduction of fracture fragments as determined by the Matta grade, is predictive of the ability to retain the native hip with acceptable outcome following acetabular fracture in the elderly. Further research must be conducted to determine predictors of adequate reduction in order to identify candidates for ORIF

Introduction. The global rapid growth of the aging population has some likelihood to create a serious crisis on health-care and economy at an unprecedented pace. To extend Healthy Life Expectancy (HALE) in a number of countries, it is desired more than ever to investigate characteristic and prognosis of numerous diseases. This enlightenment and recent studies on patient-reported outcome measures (PROMs) will drive the increasing interest in the quality of life among the world. The demand for primary THAs by 2030 would rise up to 174% in USA. It is expected that the number of the elderly will surge significantly in the future, thus more septuagenarian and octogenarian are undergoing THA. Moreover, HALE of Japanese female near the age of 75 years, followed to Singapore, is still increasing. Therefore, concerns exist about the PROMs of performing THA in this age-group worldwide. Nevertheless almost the well-established procedure, little agreement has been reached to the elderly. We aimed to clarify the mid-term PROMs after THA over 75-year old. Methods. Between 2005 and 2013, we performed 720 consecutive primary cemented THAs through a direct lateral approach. Of these, 503 female patients (655 hips) underwent THA for treatment of osteoarthritis, with a minimum follow-up of 5 years, were retrospectively enrolled into the study. We excluded 191 patients (252 hips) aged less than 65-year at the time of surgery and 58 patients (60) because of post-traumatic arthritis or previous surgery (37), or lack of data (23). Thus, 343 hips remained eligible for our study, contributed by 254 patients. We investigated Quality-adjusted life year (QALY), EuroQol 5-Dimension 5-Level scale (EQ-5D) and the Japanese Orthopaedic Association Hip-Disease Evaluation Questionnaire (JHEQ, which was a disease-specific and self-administered questionnaire, reflecting the specificity of the Japanese cultural lifestyle) in patients aged 75 years or older (154 hips, Group-E) compared with those aged 65 to 74 years (189 hips, Group-C) retrospectively. We evaluated the association between patients aged 75 years or older and the following potential risk factors, using logistic regression analysis: age, number of vertebral fractures (VFs), American Society of Anesthesiologists physical status (ASA-PS) and Charlson Comorbidity Index (CCI). A p value of < 0.05 was considered significant for the Mann-Whitney U test. Results. At a mean follow-up duration of 7.2 years, QALY, EQ-5D and JHEQ for the domain of patient satisfaction were significantly greater for Group-E than Group-C; however, there were no significant differences in JHEQ for pain, movement and mental-health between groups. On multivariate analysis, the age (odds ratio [OR] 2.48, p < .01 for EQ-5D; OR .32, p < .01 for JHEQ satisfaction), VFs (OR 1.63, p < .01 for satisfaction) and ASA-PS (OR .64, p = .31 for EQ-5D) were independent predictive risk factors for patients aged 75-year or older. Conclusions. Based on mid-term follow-up of PROMs study, we suggest that cemented THA can lead to the extension of HALE towards the super aged society and our results can be applied to a systematic analysis for the Global Burden of Disease Study related frailty

Aim. Surgical site infections caused by Staphylococcus aureus (S. aureus) are associated with considerable clinical and economic burden. Studies assessing this burden in Germany have been limited to specific institutions, selected patient groups or not specific to S. aureus infections (SAI). This study was undertaken to further understand the burden of SAI following orthopedic surgeries in Germany. Method. All patients with at least one spine, endoprosthetic hip or knee surgery between 2012 and 2015 captured in the AOK PLUS claims database were included in this analysis. SAI were identified using S. aureus-specific ICD-10 codes following surgery. Exclusion criteria included: younger than 18, SAI in the 90 days preceding index, any surgery in the 180 days preceding index, surgery at the same body location as index in the preceding 365 days, or more than one surgery of interest during index hospitalization. Cumulative incidence and incidence density were used to assess SAI. Mortality, healthcare resource utilization and costs were compared between SAI and non-SAI group during the 1year follow-up post index surgery. Multivariate analyses were conducted while controlling for sex, age, Charlson Comorbidity Index (CCI), location of surgery, length of index hospitalization, recent fractures, other bacterial infections during index hospitalization and outpatient prescriptions for antibiotics in the year pre-index. Results. In total, 74,327 patients were included who underwent a knee (21,285), hip (29,429), or spine surgery (23,613). Mean age was 69.6 years, 61.6% were female and the mean CCI was 2.3. The SAI incidence post-orthopedic surgery was 20.2 cases per 1,000 patient-years within 1 year of index hospitalization; the cumulative incidence was 1.9%. Knee surgeries were associated with lower SAI risk compared to hip surgeries (HR=0.8; p=0.024), whereas spine surgeries did not differ significantly. Compared to non-SAI group, the SAI group had on average 4.4 times the number of hospitalizations (3.1 vs. 0.7) and 7.7 times the number of hospital days (53.5 vs. 6.9), excluding the index hospitalization (p-values<0.001). One year post-orthopedic mortality was 22.38% in the SAI and 5.31% in the non-SAI group (p<0.001). The total medical costs were significantly different between SAI and non-SAI groups (42,834€ vs. 13,781€; p<0.001). Adjusting for confounders, the SAI group had nearly 2 times the all-cause direct healthcare costs (exp(b)=1.9; p<0.001); and 2.5 times the risk of death (OR=2.5; p<0.001) compared to the non-SAI group. Conclusions. S. aureus infection risk after orthopedic surgeries persists and is associated with significant economic burden and risk of mortality

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

Infection following primary total knee arthroplasty (TKA) is fortunately a relatively uncommon complication with an incidence of approximately 1%. However, because the morbidity and cost of treatment of deep prosthetic TKA infections is so high, effective prevention strategies are key quality improvement initiatives. The cause of post-operative infections are multifactorial and complex but can generally be categorised into 1) host, 2) surgical, and 3) environmental factors. The purpose of this abstract to provide an outline of these factors and their influences on the infection risk following TKA. Patient factors and optimization of modifiable risk factors have been shown to decrease the risk for infection. While the individual contributions of factors such as body mass index (BMI), diabetes, nutritional status, Charlson Comorbidity Index (CCI), and renal disease are unknown, together, they have been shown to influence infection risk. Additionally, Tayton et al. analyzed 64,566 primary TKAs in the New Zealand Joint Registry and found that male gender and prior knee surgery were also independent risk factors of development of PJI 12 months following TKA. Finally, Crowe and colleagues also identified tobacco use and Staphylococcus aureus colonization as modifiable risk factors for minimizing PJI following primary TKA. Timely administration of prophylactic antibiotics prior and after surgery has been shown to be the most effective strategy to reduce infection risk. The optimal prophylaxis regimen for all patients is unknown and in certain situations, administration of Vancomycin in additional to a conventional cephalosporin may be beneficial. However, universal administration of Vancomycin has not been shown to decrease the incidence of surgical site infections and could actually increase the risk for renal failure. Conversely, addition of antibiotics to cement during primary TKA has not been shown to reduce long term infection risk. The use of dilute betadine lavage has been shown by some authors to be beneficial. Finally, good surgical technique, proper soft tissue handling, and meticulous wound closure are all critical factors influencing the risk for infectious complications following TKA. Environmental factors have also been shown to affect infection rates following TKA. While the use of laminar flow and body exhaust suits have not been shown to significantly influence the risk for infection, minimizing operating room traffic has been shown effective in reducing the risk for contamination. Some authors have shown ultraviolet light systems to decrease airborne contaminants. In summary, factors influencing infection risk following TKA are complex and multifactorial. Patient selection, optimization of modifiable risk factors, appropriate use of antibiotics, and minimization of OR traffic are among the most common strategies to minimizing infection

Infection following primary total knee arthroplasty (TKA) is fortunately a relatively uncommon complication with an incidence of approximately 1%. However, because the morbidity and cost of treatment of deep prosthetic TKA infections is so high, effective prevention strategies are key quality improvement initiatives. The cause of post-operative infections are multifactorial and complex but can generally be categorised into 1) host, 2) surgical, and 3) environmental factors. The purpose of this abstract is to provide an outline of these factors and their influences on the infection risk following TKA. Patient factors and optimization of modifiable risk factors have been shown to decrease the risk for infection. While the individual contributions of factors such as body mass index (BMI), diabetes, nutritional status, Charlson Comorbidity Index (CCI), and renal disease are unknown, together, they have been shown to influence infection risk. Additionally, Tayton et al. analyzed 64,566 primary TKAs in the New Zealand Joint Registry and found that male gender and prior knee surgery were also independent risk factors of development of PJI 12 months following TKA. Finally, Crowe and colleagues also identified tobacco use and Staphylococcus aureus colonization as modifiable risk factors for minimizing PJI following primary TKA. Timely administration of prophylactic antibiotics prior and after surgery has been shown to be the most effective strategy to reduce infection risk. The optimal prophylaxis regimen for all patients is unknown and in certain situations, administration of Vancomycin in additional to a conventional cephalosporin may be beneficial. However, universal administration of Vancomycin has not been shown to decrease the incidence of surgical site infections and could actually increase the risk for renal failure. Conversely, addition of antibiotics to cement during primary TKA has not been shown to reduce long term infection risk. The use of dilute betadine lavage has been shown by some authors to be beneficial. Finally, good surgical technique, proper soft tissue handling, and meticulous wound closure are all critical factors influencing the risk for infectious complications following TKA. Environmental factors have also been shown to affect infection rates following TKA. While the use of laminar flow and body exhaust suits have not been shown to significantly influence the risk for infection, minimizing operating room traffic has been shown effective in reducing the risk for contamination. Some authors have shown ultraviolet light systems to decrease airborne contaminants. In summary, factors influencing infection risk following TKA are complex and multifactorial. Patient selection, optimization of modifiable risk factors, appropriate use of antibiotics, and minimization of OR traffic are among the most common strategies to minimizing infection

Introduction. Risks and benefits of bilateral total knee arthroplasty (TKA), whether simultaneous, sequential single-staged, or staged is a topic of debate. Similarly, computer-assisted navigation for TKA is controversial regarding complications, cost-effectiveness, and benefits over conventional TKA. To our knowledge, no studies have compared computer-assisted and conventional techniques for sequential bilateral TKA. We hypothesise that the computer-assisted technique has fewer complications. Methods. We retrospectively reviewed 40 computer-assisted and 36 conventional bilateral sequential TKAs from 2007–2011 with 1 year follow-up for complications. Groups were matched by age, gender, body mass index (BMI), Charlson Comorbidity Index (CCI), and American Society of Anesthesiologists Classification (ASA). Pearson's Chi-square, Fisher's exact test, and independent samples t-test were used to compare groups. Results. Our populations' mean age was 65.9 years, BMI 31.6, CCI 3.4, ASA 2.3, and a male to female ratio of 1:2. Computer-assisted demonstrated significantly better postoperative day (POD) 1 hemoglobin (p=.001), decreased number of blood transfusions (p=.001) and fewer complications (p=.023). Mean preoperative hemoglobin (Hgb) for both groups was 12.4 g/dL, but mean POD1 Hgb was 10.2 g/dL and 9.3 g/dL, for computer-assisted and conventional groups respectively. Total blood transfusion units were a mean of 1.0 and 1.7 for computer-assisted and conventional groups respectively. Seven (19%) patients in the conventional group had lethargy, altered mental status (AMS), or syncope versus none in the computer-assisted group. Subsequent Hgb levels, tourniquet time, length of stay, readmissions, and reoperations were not significantly different with numbers available between the two groups. Conclusion. Computer-assisted sequential bilateral TKAs had higher Hgb on POD1 and lower blood transfusions and complications. This may be due to violation of the femoral canal causing increased bleeding using the conventional technique. Fat emboli from the femur may have caused AMS, but did not increase incidence of pulmonary embolism in the conventional group

Background. The Perioperative Surgical Home (PSH) is a physician-led, patient centered, rapid recovery care delivery model that includes multi-specialty care teams and cost-efficient use of resources developed to deliver patient centered value based care. The purpose of this study was to compare a group of patients undergoing primary total hip arthroplasty (THA) managed in the PSH model to a matched group managed in a more traditional fashion with respect to clinical outcomes, complications, and costs. Methods. We prospectively followed the first 180 THA patients from the PSH group, comparing them to a group matched for age, Body Mass Index (BMI), American Society of Anesthesiologists (ASA) Score, and Charlson Comorbidity Index (CCI) that was treated prior to implementation of the PSH. A combination of regional anesthesia and multi-modal pain control was used to minimize patient narcotic consumption. There was a rapid de-escalation of care post-operatively. Weekly multi disciplinary meetings were held where advanced discharge planning was discussed and we evaluated successes and areas of improvement of the prior week in an effort to continuously improve. We used Wilcoxon, Chi square, and multivariate regression analysis to compare the groups for length of stay (LOS), total direct cost (TDC), complications, 30-day readmissions, and discharge location. Results. The mean age, BMI, ASA Score, and CCI was 64, 30, 3.0, and 3.5 for both groups. The LOS in the PSH group was 2.1 days, which was significantly lower than the Non Surgical Home (NSH) group at 3.6 days (P<0.001). Significantly more patients were discharged home in the PSH group, 83%, versus 71% in the NSH (P=0.006). No significant difference was found between the two groups with regard to complications (P=0.346), TDC (P=0.883), or readmissions at 30 days (P=0.637). Regarding the TDC, room and board cost $1,916 for the NSH group, and $1,375 for the PSH group secondary to the shorter LOS. This was a 28% reduction in room and board cost for the PSH group. This was offset, however, by an unforeseen increase in operating room labor cost during the study period. This cost increased from $1,672 in 2012–2013 (the period from which the NSH cohort was obtained) to $2,265 in the PSH time period. This was over a 26% increase. Multivariate analysis showed the PSH cohort was an independent variable associated with decreased LOS (P<0.001) and discharge to home (P<0.001). Conclusion. We believe the implementation of the Perioperative Surgical Home led to decreased LOS and allowed more patients to be discharged to home, without an increase in complications or readmissions. We believe this model is successful at providing patient centered value based care. The actual clinical pathway continues to be in use and is being further refined as we are regularly evaluating outcomes and finding areas of improvement

Background:. Periprosthetic joint infection (PJI) is one of the most devastating complications in patients undergoing total knee arthroplasty (TKA). Although controversy exists about the necessity of the prophylactic use of antibiotics in clean operations, the routine use of antibiotic-loaded bone cement (ALBC) has been the clinical procedure against PJI for many decades. Additionally, the combination of antibiotics has been used to broaden the antimicrobial spectrum and to enhance antimicrobial activity in a revision setting with a potentially resistant organism. Even in primary TKA, the prophylactic combination of antibiotics used as therapy should be considered on patients with a higher susceptibility to bacterial infection based on their clinical histories of PJI, rather than the lower risk population. The purpose of this study is to investigate whether the synergistic combination of antibiotics in bone cement in high risk patients can reduce PJI. Methods:. A total of 3015 knees of 1918 patients were screened for inclusion in this study based on their risk factor, and those categorized as systematically or locally high risk patients were included. Patients that were classified as “systemically high risk” received an American Society of Anesthesiologists (ASA) classification of 3 or higher and a Charlson Comorbidity Index (CCI) classification of 2 or higher (n = 212 knees, 70.7% of 300 total). Patients that were classified as “locally high risk” had a history of inflammatory arthritis, poor skin conditions, and/or recent septic knee arthritis (n = 76 knees, 25.3%). Patients with both systemically and locally high risk included 12 knees (4.0%). The 300 knees included in this study were separated into three groups based on the combination of antibiotics administered. In group 1(208 knees), gentamycin–impregnated cement was used and in group 2(48 knees) hand-mixed vancomycin with pre-mixed gentamycin cement for intraoperative management was used. In group 3 revision bone cement containing a combination of two antibiotics (gentamycin and clindamycin) was used (44 knees). The mean age was 70.9 years. The number of men and women were 31(10.3%) and 269(89.7%), respectively. The average body mass index (BMI) was 26.7 kg/m. 2. The incidence of PJI was investigated. Results:. The systemically high risk, locally high risk, and both cases in group 1 numbered 173 knees (83.2%), 31 knees (14.9%), and 4 knees (1.9%), respectively. In group 2 they numbered 26 knees (54.2%), 18 knees (37.5%), and 4 knees (8.3%), respectively. In group 3, they numbered 13 knees (29.5%), 27 knees (61.4%), and 4 knees (9.1%), respectively. There were no cases of infection in groups 2 or 3 but an infection occurred in one knee (0.3%) in group 1. There were no differences in age, gender, or BMI among groups (p > 0.05). Conclusion:. We conclude that the use of any ALBC did not seem to affect the incidence of infection following primary TKA. While combination antibiotics have been used by surgeons who may be concerned about PJI after TKA in high risk patients, our results did not indicate a significant difference, and as a result using antibiotics in bone cement to reduce PJI may be just myth

Aims

The increase in prescription opioid misuse and dependence is now a public health crisis in the UK. It is recognized as a whole-person problem that involves both the medical and the psychosocial needs of patients. Analyzing aspects of pathophysiology, emotional health, and social wellbeing associated with persistent opioid use after injury may inform safe and effective alleviation of pain while minimizing risk of misuse or dependence. Our objectives were to investigate patient factors associated with opioid use two to four weeks and six to nine months after an upper limb fracture.