With an aging population and increase in total knee arthroplasty, periprosthetic distal femur fractures (PDFFs) have increased. The differences between these fractures and native distal femur fractures (NDFF) have not been comprehensively investigated. The purpose of this study was to compare the demographic, fracture, and treatment details of PDFFs compared to NDFFs. A retrospective study of patients ≥ 18 years old who underwent surgical treatment for either a NDFF or a PDFF from 2010 to 2020 at a level 1 trauma center was performed. Demographics, AO/OTA fracture classification, quality of reduction, fixation constructs, and unplanned revision reoperation were compared between PDFF patients and NDFF patients using t-test and Fisher's exact test. 209 patients were identified with 70 patients having a PDFF and 139 patients having a NDFF. Of note, 48% of NDFF had a concomitant fracture of the ipsilateral knee (14%) or tibial plateau (15%). The most common AO/OTA classification for PDFFs was 33A3.3 (71%). NDFFs had two main AO/OTA classifications of 33C2.2 (28%) or 33A3.2. (25%). When controlling for patient age, bone quality, fracture classification, and fixation, the PDFF group had increased revision reoperation rate compared to NDFF (P < 0.05). PDFFs tend to occur in elderly patients with low bone quality, have complete metaphyseal comminution, and be isolated; whereas, NDFF tend to occur in younger patients, have less metaphyseal comminution, and be associated with other fractures. When controlling for variables, PDFF are at increased risk of unplanned revision reoperation. Surgeons should be aware of these increased risks in PDFFs and future research should focus on these unique fracture characteristics to improve outcomes

Introduction and Objective. Several factors contribute to the duration of the hospital stay in patients that undergo to total hip arthroplasty (THA), either subjective or perioperative. However, no definite evidence has been provided on the role of any of these factors on the hospitalization length. The aim of this retrospective investigation is to evaluate the correlation between several preoperative and perioperative factors and the length of hospital stay (LOS) in patients that underwent elective total hip arthroplasty. Materials and Methods. Medical records of patients that underwent THA since the beginning of 2016 to the end of 2018 were retrospectively screened. Demographics, comorbidities, renal function, whole blood count. and length of post-operative ward stay were retrieved. The association between clinical, biochemical and surgical factors and the length of hospital stay was explored by means of linear regression models. Results. A total of 743 subjects were included. Retrieved comorbidity included arterial hypertension (47%), dyslipidaemia (20%), chronic kidney disease (CKD) (12%) and diabetes mellitus (9%). The median length of post-operative hospital stay was 4 days (IQR: 2). Variables associated with linear increase of hospitalization length were the estimated Glomerular Filtration Rate (eGFR) (Beta −0.01, 95% CI −0.02, 0), CKD (Beta 0.82, 95% CI 0.29, 1.34), duration of surgery (Beta 0.69, 95% CI 0.44, 0.94). After correction for multiple confounders, the CKD (a-Beta 1.58 95%CI 0.00 – 3.22) and operation time (a-Beta 0.67, 95% CI 0.42, 0.92) were consistently associated with the outcome. Conclusions. Our analysis demonstrated a significant role played by the eGFR (as an index of renal function) in influencing the length of hospital stay

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. Acute pain following total knee replacements (TKRs) is associated with higher peri-operative opiate requirements and their side effects, longer hospital stay and lower patient satisfaction (Petersen 2014). It may also be associated with higher rates of chronic pain at 1 and 5 years (Beswick 2012). We present a novel technique using combination of Local Infiltration Anaesthesia (LIA) with PainKwell infusion system (Bupivacaine 0.5 @ 4mls and 6mls/hr) to improve pain management following TKRs. Methods. Between October 2015 and March 2016. 110 patients undergoing primary TKR were prospectively studied. All patients studied had spinal anaesthesia (SA) with diamorphine. Demographics between the two groups were similar. Group 1. SA plus LIA plus traditional multimodal analgesia. 32 patients. Group 2. SA plus LIA plus PainKwell for 48 hours rate 4mls. 38 patients. Group 3. SA plus LIA plus PainKwell for 48 hours rate 6mls. 40 patients. Results. Visual analogue pain scores demonstrated a significant difference at 8hrs, 12hrs, 24hrs and 48hrs between group 1 and 3; p<0.05. There was also a statistical difference in opiate usage at 24 hours between the three groups with group 3 using significantly less opiates compared to group 1. There was least consumption of opiates in group 3 patients across all study periods. Conclusions. This study reported that SA plus LIA and PainKwell system was effective in reducing pain following TKRs. It also demonstrated that the technique of SA plus LIA plus PainKwell for 48 hours at a rate 6mls/hr reduced opiate usage by 50% and pain by 30% for these patients. Implications. This technique may help improve rehabilitation and shorten hospital stay following total knee arthroplasties

Successful treatment of periprosthetic joint infection involves surgical intervention and identification of infecting organisms to enable targeted antibiotic therapy. Current guidelines recommend intra-operative culture sampling to include at least 4 tissue samples and for each sample to be taken with a separate instrument. We aimed to review current revision arthroplasty practice for Greater Glasgow, specifically comparing intra-operative sampling technique for infected revision cases with these guidelines. We reviewed the clinical notes of all patients undergoing lower limb revision arthroplasty procedures in Greater Glasgow Hospitals (WIG, GRI, SGH) from July 2013 to August 2014. Demographics of all cases were collected. For revision procedures performed for infection we recorded details of intraoperative samples taken (number, type and sampling technique) and time for samples to reach the laboratory. Results of microbiology cultures were reviewed. Two hundred and fifty five revision arthroplasty procedures (152 hips, 103 knees) were performed in the 12 month study period. Of these 57 (22%) were infected cases (28 hips, 29 knees). These cases were treated by 14 arthroplasty surgeons with a median number of 3 infected cases managed per surgeon (range 1–11). 58% of cases had the recommended number of tissue samples taken. The median number of microbiology samples collected was 4 (range 1–14). Most procedures (91%) had no documentation of whether separate instruments were used for sampling. Number of tissue samples taken (≥4, p=0.01), time to lab (<24 hours, p=0.03) were significantly associated with positive culture results. In Greater Glasgow, a large number of surgeons manage infected arthroplasty cases with variability in intra-operative sampling techniques. Sample collection adheres to guideline recommendations in 58% cases. Adhering to guideline standards increases the likelihood of positive tissue cultures. Implementation of a standardised approach to intra-operative sampling for infected cases may improve patient management

Demographics changes and the increasing incidence of metastatic bone disease are driving the significant issues of vertebral body (VB) fractures as an important consideration in the quality of life of the elderly. Whilst osteoporotic vertebral fractures have been widely studies both clinically and biomechanically, those fractures arising from metastatic infiltration in the spine are relatively poorly understood. Biomechanical in-vitro assessment of these structurally weaker specimens is an important methodology for gaining an understanding of the mechanics of such fractures in which a key aspect is the development of methodologies for predicting the failure load. Here we report on a method to predict the vertebral strength by combining computed tomography assessment with an engineering beam theory as an alternative to more complex finite element analyses and its verification within a laboratory scenario. Ninety-two human vertebral bodies with 3 different pathologies: osteoporosis, multiple myeloma (MM) and specimens containing cancer metastases were loaded using a define protocol and the failure loads recorded. Analysis of the resulting data demonstrated that the mean difference between predicted and experimental failure loads was 0.25kN, 0.41kN and 0.79 kN, with adjunct correlation coefficients of 0.93, 0.64 and 0.79 for osteoporotic, metastatic and MM VBs, respectively. Issues in predicting vertebral fracture arise from extra-vertebral bony formations which add to vertebral strength in osteoporotic VB but are structurally incompetent in metastatic disease. The methodology is currently used in providing better experimental design/benchmarking within in-vitro investigations together with further exploration of its utility in the clinical arena

Bony tumours of the foot account for approximately 3% of all osseous tumours. However, literature regarding os calcis tumours comprises individual case reports, short case series or literature reviews, with the last large case series in 1973. We retrospectively reviewed the medical notes and imaging for all patients with calcaneal tumours recorded in the Scottish Bone Tumour Registry since the 1940's. Demographics, presentation, investigation, histology, management and outcome were reviewed. 38 calcaneal tumours were identified. Male to female ratio 2:1, mean age at presentation 30 with heel pain and swelling, average length of symptoms 9 months. 4 cases present with pathological fracture. 24 tumours benign including 6 unicameral bone cysts, 3 chondroblastoma, 3 PVNS with calcaneal erosion, and a wide variety of individual lesions. 13 malignant tumours comprising 6 osteosarcoma, 5 chondrosarcoma and 2 Ewings sarcoma. 1 metastatic carcinoma. Tumours of the calcaneus frequently are delayed in diagnosis due to their rarity and lack of clinician familiarity. They are more common in men and have a 1 in 3 risk of malignancy, covering a wide variety of lesions. Outcome is dependent on early diagnosis, timely surgery and most importantly neo-adjuvant chemotherapy. Diagnosis is often made on plain radiograph but MRI is the gold standard. We present the largest case series of calcaneal tumours, from our experience with the Scottish Bone Tumour Registry. Despite their rarity clinicians should maintain a high index of suspicion as accurate and timely diagnosis is important to management and outcome

Summary. open tibia fractures are best treated in an orthopaedic-plastic surgical multidisciplinary setting. Introduction. Open fractures of the leg represent a severe trauma. It is often stated that combining the skills of Plastic and Orthopaedic surgeons can optimise the results of limb salvage in complex limb injury. The multidisciplinary approach, shared between plastic and orthopaedic surgeons, is likely to provide the optimal treatment of these injuries, although this mutidisciplinary simultaneous treatment is not routinely performed. Given the relatively low incidence of these traumas, a multicentric recruitment of these patients can contribute in providing an adequately numerous cohort of patients to be evaluated through the long process of soft tissue and bone healing following an open tibia fracture. We compared three centres with different protocols for management of these challenging cases. Patients & Methods. The following trauma centres, either orthoplastic or orthopaedic, were involved in a prospective observational study: Rizzoli Orthopaedic Institute/University of Bologna (leading centre) and Maggiore Hospital (Bologna), Frenchay Hospital (Bristol, Regno Unito), Jinnah Hospital (Lahore, Pakistan), a centre in the developing world who have adopted an Ortho-Plastic approach. From 01/01/2012, all patients consecutively hospitalised in the mentioned centres due to Gustilo grade 3 tibial open fractures were included in the study and propspectively followed. Demographics, mechanism of the trauma, type of lesion, timing and way of transfer to the trauma centre, as well as timing and techniques of bone and soft tissue treatment were recorded. The considered outcome measures were duration of hospitalization (main outcome measure), rate of reintervention, Enneking score at 3, 6 and 12 months, the incidence of osteomyelitis, non union, amputation and other complications. Results. The number of patients included in the first 6 months was 42. Mechanism, severity of injury and techniques regarding definitive bone reconstruction were similar accross the three centres. The main difference occured in soft-tissue management with VAC therapy being utilised by the Italian centre compared to vascularised tissue transfer in Pakistan and Britain. The mean duration of hospital stay in the Italian centre was 72 days compared with 24 days in Pakistan and 25 days in Britain. Patients treated in a centre with an orthoplastic team, therefore, spent an average of 46 fewer days in hospital (P<0.005, 95% CI −69 to −24days). Discussion. From an initial analysis of data, the duration of hospitalization is strongly influenced by the fact that a plastic procedure is performed or not. The first evaluations on the hospital management of these injuries show a relevant advantage deriving from a combined orthoplastic approach, evenwhen applied into a comparatively hostile cohort

Aim. To assess whether the Oxford Hip Score (OHS), is reflective of objectively assessed functional performance (timed up and go (TUG), 30 sec sit to stand (ST), 6 minute walk test (6MWT), stair climb performance (SCP), and gait speed (GS)) in patients undergoing total hip arthroplasty (THA). Methods. 50 patients undergoing THA were prospectively recruited after ethical approval. Demographics and objective physical performance were assessed (TUG, ST, 6MWT, SCP, GS), as was the OHS preoperatively, and at 6 weeks, 6 months and 9 to 12 months postoperatively. Pearson's correlation coefficient was used to assess relationships, with p<0.05 statistically significant. Results. Average age of the cohort was (mean (SD)) 67.8 (9.4) years in males (n=21) and 64.2 (10.2) years in females (n=29). Due to loss to follow up, 32 patients were assessed at 6 weeks, 29 at 6 months and 26 at 9 to 12 months. Preoperatively OHS correlated weakly with TUG (r = − 0.327, p=0.022), ST (r = 0.345, p=0.015) and SCP (r = − 0.330, p=0.022). At 6 months, OHS correlated moderately with all the objective measures assessed; TUG (r = − 0.480, p=0.006), ST (r = 0.454, p=0.010), 6MWT (r=0.507, p = 0.004) and SCP (r = 0.534, p=0.002), with the relationships less evident at 6 weeks (no significant correlations) and 9 to 12 months (moderate correlation with 6MWT only (r = 0.512, p=0.009). Conclusions. The OHS most accurately reflects objective functional performance at 6 months postoperatively, perhaps indicating this time point may be optimal in terms of postoperative recovery

Objectives

Evidence -based medicine (EBM) is designed to inform clinical decision-making within all medical specialties, including orthopaedic surgery. We recently published a pilot survey of the Canadian Orthopaedic Association (COA) membership and demonstrated that the adoption of EBM principles is variable among Canadian orthopaedic surgeons. The objective of this study was to conduct a broader international survey of orthopaedic surgeons to identify characteristics of research studies perceived as being most influential in informing clinical decision-making.