We examined the one-year risk of symptomatic venous thromboembolism (VTE) following primary total hip replacement (THR) among Danish patients and a comparison cohort from the general population. From the Danish Hip Arthroplasty Registry we identified all primary THRs performed in Denmark between 1995 and 2010 (n = 85 965). In all, 97% of patients undergoing THR received low-molecular-weight heparin products during hospitalisation. Through the Danish Civil Registration System we sampled a comparison cohort who had not undergone THR from the general population (n = 257 895). Among the patients undergoing THR, the risk of symptomatic VTE was 0.79% between 0 and 90 days after surgery and 0.29% between 91 and 365 days after surgery. In the comparison cohort the corresponding risks were 0.05% and 0.12%, respectively. The adjusted relative risks of symptomatic VTE among patients undergoing THR were 15.84 (95% confidence interval (CI) 13.12 to 19.12) during the first 90 days after surgery and 2.41 (95% CI 2.04 to 2.85) during 91 to 365 days after surgery, compared with the comparison cohort. The relative risk of VTE was elevated irrespective of the gender, age and level of comorbidity at the time of THR.

We concluded that THR was associated with an increased risk of symptomatic VTE up to one year after surgery compared with the general population, although the absolute risk is small.

Aims. There are reports of a marked increase in perioperative mortality in patients admitted to hospital with a fractured hip during the COVID-19 pandemic in the UK, USA, Spain, and Italy. Our study aims to describe the risk of mortality among patients with a fractured neck of femur in England during the early stages of the COVID-19 pandemic. Methods. We completed a multicentre cohort study across ten hospitals in England. Data were collected from 1 March 2020 to 6 April 2020, during which period the World Health Organization (WHO) declared COVID-19 to be a pandemic. Patients ≥ 60 years of age admitted with hip fracture and a minimum follow-up of 30 days were included for analysis. Primary outcome of interest was mortality at 30 days post-surgery or postadmission in nonoperative patients. Secondary outcomes included length of hospital stay and discharge destination. Results. In total, 404 patients were included for final analysis with a COVID-19 diagnosis being made in 114 (28.2%) patients. Overall, 30-day mortality stood at 14.4% (n = 58). The COVID-19 cohort experienced a mortality rate of 32.5% (37/114) compared to 7.2% (21/290) in the non-COVID cohort (p < 0.001). In adjusted analysis, 30-day mortality was greatest in patients who were confirmed to have COVID-19 (odds ratio (OR) 5.64, 95% confidence interval (CI) 2.95 to 10.80; p < 0.001) with an adjusted excess risk of 20%, male sex (OR 2.69, 95% CI 1.37 to 5.29; p = 0.004) and in patients with ≥ two comorbidities (OR 4.68, CI 1.5 to 14.61; p = 0.008). Length of stay was also extended in the COVID-19 cohort, on average spending 17.6 days as an inpatient versus 12.04 days in the non-COVID-19 group (p < 0.001). Conclusion. This study demonstrates that patients who sustain a neck of femur fracture in combination with COVID-19 diagnosis have a significantly higher risk of mortality than would be normally expected. Cite this article: Bone Joint Open 2020;1-11:697–705

Aim. Management of bone and joint infection can be technically complex and often requires a prolonged course of antibiotics. Traditionally, bone and joint infection management utilises nurse-led outpatient parenteral antibiotic therapy (OPAT) where adherence is unlikely to be an issue. However, with increasing evidence in favour of oral therapy, the question of adherence merits further consideration. We describe the adherence of both oral (PO) and self-administered intravenous (IV) antibiotics in the treatment of bone and joint infection using paper questionnaires (8-item Modified Morisky Adherence Score (MMAS)) and, in a subset of participants, electronic pill containers (Medication Event Monitoring Systems*). Method. All eligible participants enrolled in the OVIVA trial (2010–2015) were randomised to six weeks of either PO or IV antibiotic treatment arms. Self-administering patients were followed up with questionnaires at day 14 and 42. A subset of PO participants was also given the medication event monitoring system* in order to validate the adherence questionnaires. The results were correlated with treatment failures at one-year follow-up. Results. 1,054 participants were enrolled in the OVIVA study. At day 14, 68% of participants recorded high adherence in both the IV (N=72) and PO arms (N=303) using the 8-item MMAS. At day 42, only 51% maintained high adherence in the PO arm (N=323) as compared to a 68% in the self-administered IV arm (N=80). The medication event monitoring system* results at day 42 demonstrated that 51% of participants achieved adherence of 100% (range 45–100). There was no statistically significant correlation between adherence and treatment failure in either randomised treatment arm. Conclusions. This is the first large scale study to quantitatively assess compliance with antibiotics in bone and joint infections using established adherence tools. Our results suggest that oral antibiotic adherence decreases significantly over time. Despite the absence of apparent excess risk of therapeutic failure in this trial, we strongly advise careful patient education and adherence support in order to optimise clinical outcomes. Acknowledgements. The OVIVA study is funded by the National Institute for Health research (Health Technology Assessment); project number 11/36/29. *MEMS® Medication Event Monitoring System

We studied the rate of revision in 84 consecutive total hip replacements performed for failed osteosynthesis of femoral neck fractures and compared it with that for primary arthroplasty for osteoarthritis. The age and sex adjusted risk of prosthetic failure was 2.5 times higher after failure of fixation, but all the excess risk was in patients over 70 years of age. There were radiographic signs of loosening of the femoral component at five to 12 years after secondary arthroplasty in six of 33 survivors. In general, the results of secondary replacement were no worse than those obtained after primary arthroplasty for femoral neck fracture. We consider that internal fixation should be the primary procedure: total hip replacement is a safe secondary procedure when osteosynthesis fails

Introduction. The goal of tibial tray placement in total knee arthroplasty (TKA) is to maximize tibial surface coverage while maintaining proper rotation. Maximizing tibial surface coverage without component overhang reduces the risk of tibial subsidence. Proper tibial rotation avoids excess risk of patellar maltracking, knee instability, inappropriate tibial loading, and ligament imbalance. Different tibial tray designs offer varying potential in optimizing the relationship between tibial surface coverage and rotation. Patient specific instrumentation (PSI) generates customized guides from an MRI- or CT-based preoperative plan for use in TKA. The purpose of the present study was to utilize MRI information, obtained as part of the PSI planning process, to determine, for anatomic, symmetric, and asymmetric tibial tray designs, (1) which tibial tray design achieves maximum coverage, (2) the impact of maximizing coverage on rotation, and (3) the impact of establishing neutral rotation on coverage. Methods. In this prospective comparative study, MR images for 100 consecutive patients were uploaded into Materialise™ PSI software that was used to evaluate characteristics of tibial component placement. Tibial component rotation and surface coverage was analyzed using the preoperative planning software. Anatomic (Persona™), symmetric (NexGen™), and asymmetric (Natural-Knee II™) designs from a single manufacturer (Zimmer™) were evaluated to assess the relationship of tibial coverage and tibial rotation. Tibial surface coverage, defined as the proportion of tibial surface area covered by a given implant, was measured using Adobe Photoshop™ software (Figure 1). Rotation was calculated with respect to the tibial AP axis, which was defined as the line connecting the medial third of the tibial tuberosity and the PCL insertion. Results. When tibial surface coverage was maximized, the anatomic tray compared to the symmetric/asymmetric trays showed significantly higher surface coverage (82.1% vs 80.4/80.1%; p<0.01), significantly less deviation from the AP axis (0.3° vs 3.0/2.4°; p<0.01), and a significantly higher proportion of cases within 5° of the AP axis (97% vs 73/77%). When constraining rotation to the AP axis, the anatomic tray showed significantly higher surface coverage compared to the symmetric/asymmetric trays (80.8% vs 76.3/75.8%; p<0.01). No significant differences were found between symmetric and asymmetric trays. Discussion. We found that the anatomic tibial tray resulted in significantly higher tibial coverage with significantly less deviation from the AP axis compared to the symmetric and asymmetric trays. When rotation was constrained to the AP axis, the anatomic tray resulted in significantly higher tibial coverage than the symmetric and asymmetric trays. Tibial rotation is recognized as an important factor in the success of a total knee replacement. Maximizing coverage with the least compromise in rotation is the goal for tibial tray design. In this study, the anatomic tibia seemed to optimize the relationship between tibial surface coverage and rotation. This study additionally illustrates the way by which advanced preoperative planning tools (ie. MRI/computer reconstructions) allow us to obtain valuable information with regard to implant design

We investigated the association of Dupuytren’s contracture with smoking and with alcohol by a case-control study in which 222 patients having an operation for this condition were matched for age, operation date and gender with control patients having other orthopaedic operations. Fifty of the cases were also each matched with four community controls. Data were collected by postal questionnaire. Dupuytren’s contracture needing operation was strongly associated with current cigarette smoking (adjusted odds ratio 2.8 (95% confidence interval (CI) 1.5 to 5.2)). The mean lifetime cigarette consumption was 16.7 pack-years for the cases compared with 12.0 pack-years for the controls (p = 0.016). Dupuytren’s contracture was also associated with an Alcohol Use Disorders Test score greater than 7 (adjusted odds ratio 1.9 (95% CI 1.02 to 3.57)). Mean weekly alcohol consumption was 7.3 units for cases and 5.4 units for controls (p = 0.016). The excess risk associated with alcohol did not appear to be due to a confounding effect of smoking, or vice versa. Smoking increases the risk of developing Dupuytren’s contracture and may contribute to its prevalence in alcoholics, who tend to smoke heavily

The goal of tibial tray placement in total knee arthroplasty (TKA) is to maximise tibial surface coverage while maintaining proper rotation. Maximising tibial surface coverage without component overhang reduces the risk of tibial subsidence. Proper tibial rotation avoids excess risk of patellar maltracking, knee instability, inappropriate tibial loading, and ligament imbalance. Different tibial tray designs offer varying potential in optimising the relationship between tibial surface coverage and rotation. Patient specific instrumentation (PSI) generates customised guides from an MRI- or CT-based preoperative plan for use in TKA. The purpose of the present study was to utilise MRI information, obtained as part of the PSI planning process, to determine, for anatomic, symmetric, and asymmetric tibial tray designs, (1) which tibial tray design achieves maximum coverage, (2) the impact of maximising coverage on rotation, and (3) the impact of establishing neutral rotation on coverage. MR images for 100 consecutive patients were uploaded into Materialise™ PSI software that was used to evaluate characteristics of tibial component placement. Tibial component rotation and surface coverage was analysed using the preoperative planning software. Anatomic (Persona™), symmetric (NexGen™), and asymmetric (Natural-Knee II™) designs from a single manufacturer (Zimmer™) were evaluated to assess the relationship of tibial coverage and tibial rotation. Tibial surface coverage, defined as the proportion of tibial surface area covered by a given implant, was measured using Adobe Photoshop™ software. Rotation was calculated with respect to the tibial AP axis, which was defined as the line connecting the medial third of the tibial tuberosity and the PCL insertion. When tibial surface coverage was maximised, the anatomic tray compared to the symmetric/asymmetric trays showed significantly higher surface coverage (82.1% vs 80.4/80.1%; p<0.01), significantly less deviation from the AP axis (0.3° vs 3.0/2.4°; p<0.01), and a significantly higher proportion of cases within 5° of the AP axis (97% vs 73/77%). When constraining rotation to the AP axis, the anatomic tray showed significantly higher surface coverage compared to the symmetric/asymmetric trays (80.8% vs 76.3/75.8%; p<0.01). No significant differences were found between symmetric and asymmetric trays. We found that the anatomic tibial tray resulted in significantly higher tibial coverage with significantly less deviation from the AP axis compared to the symmetric and asymmetric trays. When rotation was constrained to the AP axis, the anatomic tray resulted in significantly higher tibial coverage than the symmetric and asymmetric trays. Tibial rotation is recognised as an important factor in the success of a total knee replacement. Maximising coverage with the least compromise in rotation is the goal for tibial tray design. In this study, the anatomic tibia seemed to optimise the relationship between tibial surface coverage and rotation. This study additionally illustrates the way by which advanced preoperative planning tools (ie. MRI/computer reconstructions) allow us to obtain valuable information with regard to implant design

Aims

Cementing in arthroplasty for hip fracture is associated with improved postoperative function, but may have an increased risk of early mortality compared to uncemented fixation. Quantifying this mortality risk is important in providing safe patient care. This study investigated the association between cement use in arthroplasty and mortality at 30 days and one year in patients aged 50 years and over with hip fracture.

We investigated the excess mortality risk associated with fractures of the hip. Data related to 29 134 patients who underwent surgery following a fracture of the hip were obtained from the Scottish Hip Fracture Audit database. Fractures due to primary or metastatic malignancy were excluded. An independent database (General Register Office (Scotland)) was used to validate dates of death. The observed deaths per 100 000 of the population were then calculated for each group (gender, age and fracture type) at various time intervals up to eight years. A second database (Interim Life Tables for Scotland, Scottish Government) was then used to create standardised mortality ratios. Analysis showed that mortality in patients aged > 85 years with a fracture of the hip tended to return to the level of the background population between two and five years after the fracture. In those patients aged < 85 years excess mortality associated with hip fracture persisted beyond eight years. Extracapsular hip fractures and male gender also conferred increased risk

Aims

To benchmark the radiation dose to patients during the course of treatment for a spinal deformity.

Aims

The aim of this study was to quantify the risk of developing cancer from the exposure to radiation associated with surgery to correct limb deformities in children.

Aims

To evaluate whether an ultra-low-dose CT protocol can diagnose selected limb fractures as well as conventional CT (C-CT).

The August 2015 Knee Roundup360 looks at: Two days as good as three in TKA; Bilateral TKA: minimising the risks; Tranexamic acid in knee arthroplasty: everyone should be using it, but how?; Initial follow-up for knee arthroplasty?; Navigation finds its niche?; Another take on navigation?; Multimodal care for early knee osteoarthritis; ACL graft fixation methods under the spotlight

The August 2015 Trauma Roundup³⁶⁰ looks at: Thromboprophylaxis not required in lower limb fractures; Subclinical thyroid dysfunction and fracture risk: moving the boundaries in fracture; Posterior wall fractures refined; Neurological injury and acetabular fracture surgery; Posterior tibial plateau fixation; Tibial plateau fractures in the longer term; Comprehensive orthogeriatric care and hip fracture; Compartment syndrome: in the eye of the beholder?

The June 2013 Spine Roundup³⁶⁰ looks at: the benefit of MRI in the follow-up of lumbar disc prolapse; gunshot injury to the spinal cord; the link between depression and back pain; floating dural sack sign; short segment fixation at ten years; whether early return to play is safer than previously thought; infection in diabetic spinal patients; and dynesis.