Introduction. The hematoma occurring at a fracture site is known to play an important role in fracture healing. Previously, we demonstrated that fracture hematoma contained multilineage mesenchymal progenitor cells. On the other hand, the process of fracture healing is associated by two different mechanisms, intramembranous and endochondral. However, there are no reports proving the details about cellular analysis in the process of endochondoral ossification. Hypothesis. We hypothesized that one of the cell origins for endochondral ossification after fracture was hematoma. Materials & Methods. Fracture hematoma was obtained during osteosynthesis. Hematoma-derived cells were isolated and cultured for 5-weeks of chondrogenic induction followed by 2-weeks hypertrophic induction using pellet culture system. The pellets were analyzed histologically and immunohistochemically. The gene expression levels of chondrogenic, hypertrophic, osteogenic and angiogenic markers were measured by real-time PCR. Results. The histological and immunohistochemical analysis revealed that the Hematoma-derived cells differentiated into hypertrophic chondrocytes through chondrocytes, and finally differentiate into calcifying chondrocytes. The same trend was seen in the gene expression using real-time PCR analysis. Discussion & Conclusions. Our results suggest that fracture hematoma may be an origin of cells which play key roles in the process of endochondoral ossification during fracture healing

Introduction. Low-intensity pulsed ultrasound (LIPUS) has been reported to enhance healing of fracture and nonunion. Bone morphogenetic protein-7 (BMP-7) has also been reported to promote bone formation. Recently, we demonstrated progenitor cells with osteogenic/chondrogenic differentiation potential existed in human fracture hematoma and nonunion tissue. Hypothesis. We hypothesised the combined application of LIPUS and BMP-7 would cause major effect on osteogenesis of hematoma-derived cells (HCs) and nonunion tissue-derived cells (NCs). Materials & Methods. HCs and NCs were isolated, and cultured. The cells were divided into two groups: (1) BMP-7 group: cells cultured in osteogenic medium (OM), and (2) BMP-7 + LIPUS group: cells cultured in OM with LIPUS treatment. LIPUS (30 mW/cm2, intensity at 1.5 MHz) was given for 20 minutes daily. Osteogenic differentiation potential and proliferation were analysed. Results. ALP activity, the gene expression of osteogenic genes, and mineralisation of HCs and NCs were shown to be higher in BMP-7 + LIPUS group than in BMP-7 group. There was no significant difference in cell proliferation between the two groups. Discussion. Our findings demonstrated the significant effect of LIPUS on the osteogenic differentiation of HCs and NCs induced by BMP-7. This study may provide significant evidence for the clinical combined application of BMP-7 and LIPUS for the treatment of severe bone fracture and nonunion

Aims. The aim of this study was to investigate the association between additional rehabilitation at the weekend, and in-hospital mortality and complications in patients with hip fracture who underwent surgery. Methods. A retrospective cohort study was conducted in Japan using a nationwide multicentre database from April 2010 to March 2018, including 572,181 patients who had received hip fracture surgery. Propensity score matching was performed to compare patients who received additional weekend rehabilitation at the weekend in addition to rehabilitation on weekdays after the surgery (plus-weekends group), as well as those who did not receive additional rehabilitation at the weekend but did receive weekday rehabilitation (weekdays-only group). After the propensity score matching of 259,168 cases, in-hospital mortality as the primary outcome and systemic and surgical complications as the secondary outcomes were compared between the two groups. Results. The plus-weekends group was significantly associated with lower in-hospital mortality rates compared with the weekdays-only group (hazard ratio 0.86; 95% confidence interval 0.8 to 0.92; p < 0.001). Systemic complications such as acute coronary syndrome, heart failure, renal failure, and sepsis were significantly lower in the plus-weekends group, whereas urinary tract infection (UTI) and surgical complications such as surgical site infection and haematoma were significantly higher in the plus-weekends group. Conclusion. Additional weekend rehabilitation was significantly associated with lower in-hospital mortality, as well as acute coronary syndrome, heart failure, renal failure, and sepsis, but was also significantly associated with a higher risk of UTI and surgical complications. This result can facilitate the effective use of the limited rehabilitation resources at the weekend and improve the clinical awareness of specific complications. To establish more robust causal associations between additional rehabilitation over the weekend and clinical outcomes, further prospective studies or randomized controlled trials with larger sample sizes are warranted. Cite this article: Bone Joint J 2023;105-B(8):872–879

Aims. Despite multiple trials and case series on hip hemiarthroplasty designs, guidance is still lacking on which implant to use. One particularly deficient area is long-term outcomes. We present over 1,000 consecutive cemented Thompson’s hemiarthroplasties over a ten-year period, recording all accessible patient and implant outcomes. Methods. Patient identifiers for a consecutive cohort treated between 1 January 2003 and 31 December 2011 were linked to radiographs, surgical notes, clinic letters, and mortality data from a national dataset. This allowed charting of their postoperative course, complications, readmissions, returns to theatre, revisions, and deaths. We also identified all postoperative attendances at the Emergency and Outpatient Departments, and recorded any subsequent skeletal injuries. Results. In total, 1,312 Thompson’s hemiarthroplasties were analyzed (mean age at surgery 82.8 years); 125 complications were recorded, necessitating 82 returns to theatre. These included 14 patients undergoing aspiration or manipulation under anaesthesia, 68 reoperations (5.2%) for debridement and implant retention (n = 12), haematoma evacuation (n = 2), open reduction for dislocation (n = 1), fixation of periprosthetic fracture (n = 5), and 48 revised stems (3.7%), for infection (n = 13), dislocation (n = 12), aseptic loosening (n = 9), persistent pain (n = 6), periprosthetic fracture (n = 4), acetabular erosion (n = 3), and metastatic bone disease (n = 1). Their status at ten years is summarized as follows: 1,180 (89.9%) dead without revision, 34 (2.6%) dead having had revision, 84 (6.6%) alive with the stem unrevised, and 14 (1.1%) alive having had revision. Cumulative implant survivorship was 90.3% at ten years; patient survivorship was 7.4%. Conclusion. The Thompson’s stem demonstrates very low rates of complications requiring reoperation and revision, up to ten years after the index procedure. Fewer than one in ten patients live for ten years after fracture. This study supports the use of a cemented Thompson’s implant as a cost-effective option for frail hip fracture patients. Cite this article: Bone Jt Open 2022;3(9):710–715

Aims. Surgical site infection can be a devastating complication of hemiarthroplasty of the hip, when performed in elderly patients with a displaced fracture of the femoral neck. It results in a prolonged stay in hospital, a poor outcome and increased costs. Many studies have identified risk and prognostic factors for deep infection. However, most have combined the rates of infection following total hip arthroplasty and internal fixation as well as hemiarthroplasty, despite the fact that they are different entities. The aim of this study was to clarify the risk and prognostic factors causing deep infection after hemiarthroplasty alone. Patients and Methods. Data were extracted from a prospective hip fracture database and completed by retrospective review of the hospital records. A total of 916 patients undergoing a hemiarthroplasty in two level II trauma teaching hospitals between 01 January 2011 and 01 May 2016 were included. We analysed the potential peri-operative risk factors with univariable and multivariable logistic regression analysis. Results. A total of 92 patients (10%) had a surgical site infection, and 44 (4.9%) developed a deep infection. After univariable analyses, the multivariable model showed that the level of experience of the surgeon measured by the number of hemiarthroplasties performed per year was a significant prognostic factor (odds ratio (OR) 0.93, p = 0.042) for the development of an infection. Secondly, the development of a haematoma (OR 9.6, p < 0.001), a re-operation (OR 4.7, p = 0.004) and an operating time of < 45 mins (OR 5.1, p = 0.002) or > 90 mins (OR 2.7, p = 0.034) were also significant factors. Conclusion. There was a significant association between the experience of the surgeon and the rate of deep infection. Secondly, a haematoma, a re-operation and both shorter and longer operating times were associated with an increased risk of deep infection after hemiarthroplasty. No association was found between deep infection and the anatomical approach, the time when surgery was undertaken and the use of a drain. Cite this article: Bone Joint J 2017;99-B:1088–94

British national guidelines recommend agents which antagonise factor Xa or warfarin as prophylaxis of venous thromboembolism (VTE) in lower limb arthroplasty. However, they discourage the use of aspirin prophylaxis. We conducted a prospective, multi-centre audit between two national centres, Ninewells Hospital in Dundee and the Royal Infirmary in Edinburgh to compare bleeding and VTE risk. Only Edinburgh routinely uses aspirin as VTE prophylaxis. The study comprises a number of cycles from 2013 to 2015. Consecutive groups of patients were identified prospectively using elective theatre data and information extracted from their case-notes on type of VTE prophylaxis, VTE occurrence, wound complications and length of hospital stay for a period of nine weeks post-operatively. 262 Edinburgh patients and 92 Dundee patients were included. Most Edinburgh patients were prescribed aspirin in hospital and on discharge (188/262, 71.8%), in line with local protocol. In Dundee, dalteparin was most commonly prescribed in hospital (68/92, 73.9%) and rivaroxaban on discharge (57/92, 62.0%). The Edinburgh group had a 1.5% incidence of pulmonary embolus (PE) and a 1% rate of deep venous thrombosis (DVT), 2% had problems with wound haematoma and one patient (0.4%) required a transfusion; no wound washouts were required. In Dundee there was 0% PE, 2% DVT, 5% had problems with haematoma, 3% required transfusion and 2% required washout. There was no difference in length of hospital stay, with a mode of 4 days for both centres. Non-fatal PE was prevented in Dundee patients but possibly at the cost of greater incidence of wound complications

Aims

Factors associated with high mortality rates in geriatric hip fracture patients are frequently unmodifiable. Time to surgery, however, might be a modifiable factor of interest to optimize clinical outcomes after hip fracture surgery. This study aims to determine the influence of postponement of surgery due to non-medical reasons on clinical outcomes in acute hip fracture surgery.

About 81,000 total knee replacements are implanted in the United Kingdom annually. Conventionally pneumatic tourniquet and surgical drains have been used in total knee arthroplasty. However, no definite evidence or guidelines exist to support their use. The present study aims to look for any difference in perioperative recovery and complications following use of pneumatic tourniquet and surgical drains in knee replacement surgery. We retrospectively analysed 60 total knee arthroplasties performed by 3 different surgeons at our hospital during January 2007 to June 2010. A sample size of 20 patients in each group was evaluated. Group 1: used tourniquet and drain; Group 2: used tourniquet but no drain; Group 3: didn't use tourniquet but used drain. Data was collected and analysed using statistical means, t-test & analysis of variance. Parameters compared were surgical (anaesthetic) time, mean postoperative haemoglobin at 24 hrs, blood transfusion rate, haematoma formation, wound infection, pain, deep vein thrombosis and infection at discharge. At 6 weeks clinical follow up letters were analysed. Our results reveal that there is no significant difference in duration of surgery in either group. Use of tourniquets didn't improve on surgical time (123–133 minutes). Our Local Hospital Pain Score was used (1 no pain, 2 mild, 3 moderate, 4 severe and 5 worst imaginable pain). No difference at discharge was seen in either group. Similarly no difference was seen in either group with postoperative haematoma formation with one case (5%) in Group 1 and 3 respectively. Although the immediate postoperative haemoglobin (Hb%) was comparable in all 3 groups, Group 3 patients received more blood transfusion compared to other groups based on clinical grounds. About 50 % of Group 3 needed blood transfusion compared to 10% in Group 1 and 5% in Group 2. There was only one proven case of superficial infection at 6 weeks (Group 2) which responded well to antibiotics. There were 4 cases of cellulitis noted at 6 weeks (3 in Group 2 and 1 in Group 3) which responded to oral antibiotics. No deep infection was noted. The mean hospital stay in hospital was 6.5 days in Group 1, 5.5 days in Group 2 and 8 days in Group 3. There was no difference in rate of post-operative deep vein thrombosis (5% in Group 1 and 3). The present study with the use of tourniquet and surgical drain in total knee arthroplasty showed no significant difference in surgical time and incidence of postoperative haematoma, deep vein thrombosis. Pain score at discharge was comparable and so was the infection rate. Patients in Group 2 (used tourniquet but no surgical drain) had least hospital stay (mean 5.5 days) and least blood transfusion rate (5%). Decision to use pneumatic tourniquet & drain still lies with the operating surgeon. We recommend a randomised control study for further evidence

Aims

Musculoskeletal infection is a devastating complication in both trauma and elective orthopaedic surgeries that can result in significant morbidity. Aim of this study was to assess the effectiveness and complications of local antibiotic impregnated dissolvable synthetic calcium sulphate beads (Stimulan Rapid Cure) in the hands of different surgeons from multiple centres in surgically managed bone and joint infections.

Aims

Acetabular fractures are associated with long-term morbidity. Our prospective cohort study sought to understand the recovery trajectory of this injury over five years.

Injuries to growth plates may initiate the formation of reversible or irreversible bone-bridges, which may lead to partial or full closure of the growth plate resulting in bone length discrepancy, axis deviation or joint deformity. Blood vessels and vascular invasion are essential for the formation of new bone tissue. The aim of our study was to investigate the spatial and temporal expression VEGF and its receptors R1 and R2 as well as the ingrowth of vessels in the formation of bone bridges in a rat physeal injury model. Quantitative Real Time - Polymerase Chain Reaction (qRT-PCR) was performed for Vascular Endothelial Growth Factor (VEGF) and its R1 and R2 receptors. Samples from the proximal epiphysis, physis and metaphysis of the tibial bone were prepared for immunohistochemical analysis to demonstrate the spatial expression of VEGF and its R1 and R2 receptors as well as laminin. Kinetic expression of VEGF and VEGF-R1 mRNA documented a tendency towards an expression increase on day 7. Histological analysis showed a haematoma containing bone fragments on day 1which was replaced by a bony bridge by day 14. This remodelled and consolidated by day 82. These trabeculae were accompanied by vessel formation. Expression of VEGF was observed on the bone fragments and the haematoma from day 1 through to day 82. Although VEGF-R1 was expressed at all time points the expression of VEGF-R2 was noted until the 14th day. Physeal bone bridge formation is a combination of both enchondral and intramembranous ossification. This is in part triggered by the bony debris observed within the lesion in the first few days. By washing this debris out the likelihood of bone bridge formation may be reduced. We recommend this practice when operating on the physis in order to avoid iatrogenic physeal bar formation

Background. To improve patient pathways we have, in selected patients, begun to acutely apply circular (rather than temporary monolateral) fixators with simultaneous or subsequent soft tissue closure. We present early results. Methods. Adult patients treated using an Ilizarov frame prior to soft tissue management were identified from our Ilizarov database. This data was supplemented by medical record review. Results. 26 cases were identified (22 open fractures (11 IIIA, 11 IIIB), 1 compartment syndrome and 3 infected salvage). All IIIA injuries were closed acutely alongside frame application. In IIIB fractures, 3 were closed following acute shortening, 1 required a local flap and 7 free tissue transfer. Soft tissue reconstruction was simultaneous to frame application in 5 patients, the remainder within 72 hours. In salvage cases, 2 required free and one a local muscle flap, all after frame application. There were no soft tissue cover failures. One patient underwent evacuation of a flap haematoma, there were no other unexpected returns to theatre for soft tissue problems. No patients required adjustment of frame components to allow soft tissue access. Conclusion. This approach appears to simplify treatment, reducing length of stay. We are collecting a matched patient series treated by traditional pathways for comparison

Introduction. Increasing numbers of elderly patients are being prescribed Clopidogrel, an anti-platelet agent for medical reasons. There are no international guidelines as to the management of patients with hip fractures on Clopidogrel in peri-operative period especially in relation to timing of the surgery. In Waterford Regional Hospital in Ireland, hip fracture surgery is deferred for 4 days and platelets are reserved for the operative/post-operative period, in case they have significant bleeding or an associated complication. We conducted a retrospective study on patients admitted over a period of 1 year. Materials and methods. A retrospective review of case notes was performed on all the hip fractures on Clopidogrel that had been admitted over last 1 year. Age, Sex, ASA, number of cancellations, operation performed, length of stay, post-op complications including wound, blood & platelet transfusions data were recorded. Results. Over this period, we admitted 53 patients who sustained hip fractures who were on plavix. The mean age was 80.6 years and the male:female ratio was 25:28. The mean length of stay was 23.4 days (range 3 to 63 days). There was an average delay of 5.37 days between admission and surgery (range 1 to 11 days). An average drop of 1.16 gm between pre-operative and post-operative hemoglobin was noted (range 8.7 gm to 15.7 gm pre-operatively and 7.3 gm to 15 gm post-operatively). There were no wound hematomas or prolonged wound oozes. Only 2 of those patients needed platelet transfusions intra-operatively. The RCC transfusion rate was 0.86 units of blood/per patient. Conclusion. The policy of delaying surgery for 4 days needs to be questioned. There were no incidences of bleeding or hematoma formation in all of our patients. The ideal time to operate on hip fracture patients is within 24–48 hours of admission after medical optimisation

Using data from the Norwegian Hip Fracture Register, 8639 cemented and 2477 uncemented primary hemiarthroplasties for displaced fractures of the femoral neck in patients aged > 70 years were included in a prospective observational study. A total of 218 re-operations were performed after cemented and 128 after uncemented procedures. Survival of the hemiarthroplasties was calculated using the Kaplan-Meier method and hazard rate ratios (HRR) for revision were calculated using Cox regression analyses. At five years the implant survival was 97% (95% confidence interval (CI) 97 to 97) for cemented and 91% (95% CI 87 to 94) for uncemented hemiarthroplasties. Uncemented hemiarthroplasties had a 2.1 times increased risk of revision compared with cemented prostheses (95% confidence interval 1.7 to 2.6, p < 0.001). The increased risk was mainly caused by revisions for peri-prosthetic fracture (HRR = 17), aseptic loosening (HRR = 17), haematoma formation (HRR = 5.3), superficial infection (HRR = 4.6) and dislocation (HRR = 1.8). More intra-operative complications, including intra-operative death, were reported for the cemented hemiarthroplasties. However, in a time-dependent analysis, the HRR for re-operation in both groups increased as follow-up increased. This study showed that the risk for revision was higher for uncemented than for cemented hemiarthroplasties

Aim. Simultaneous application of Ilizarov frames and free muscle flaps to treat osteomyelitis or infected non-unions is currently not standard practice in the UK, in part related to logistical issues, surgical duration and challenging access for microvascular anastomosis. We present the outcomes for 56 such patients. Methods. Retrospective single centre consecutive series between 2005–2017. We recorded comorbidities, Cierny-Mader and Weber-Cech classification, the Ilizarov method used, flap and anastomosis used, follow-up duration, time to union and complications. Results. 56 patients (55 tibiae and 1 forearm) were included (mean age 48 years). Thirty-four cases had osteomyelitis (20/34 Cierny-Mader Stage IV) and 22 had an infected non-union (14/22 Weber-Cech Type E or F). Forty-six patients had a segmental defect after resection. Monofocal compression was used in 14, monofocal distraction in 15, bifocal compression/distraction in 8, bone transport in 9 and a protective frame in 10. 8/56 had an ankle fusion, 7/56 had an angular deformity corrected at the same time and 32 also had local antibiotic carrier inserted. Forty-six gracilis, 9 latissimus dorsi and 1 rectus abdominus flaps were used. Six cases required urgent flap re-exploration (5 anastomotic revisions and 1 haematoma washout) with 4/6 successfully salvaged. Two cases suffered total flap failure (3.6%). Both had successful revision free muscle flaps with the frame in situ at 10 and 16 days respectively. There were no partial flap failures and no failures in bone transport frames. Mean follow-up was 22 months (4–89). Excluding three cases that still have a frame on, 42/43 (97.7%) achieved bony union. Recurrence of infection occurred in 8.9%. All were infection free at final follow-up after further surgery. Conclusions. With the right expertise, simultaneous Ilizarov frame and free muscle flap is safe and effective in treating complex limb infection, and is not associated with an increased flap failure rate. Level of evidence. III

We retrospectively reviewed 183 children with a simple fracture of the distal radius, with or without fracture of the ulna, treated by closed reduction and cast immobilisation. The fracture redisplaced after an initial, acceptable closed reduction in 46 (25%). Complete initial displacement was identified as the most important factor leading to redisplacement. Other contributing factors were the presence of an ipsilateral distal ulnar fracture, and the reduction of completely displaced fractures under deep sedation or local haematoma block. We recommend that completely displaced fractures of the distal radius in children should be reduced under general anaesthesia, and fixed by primary percutaneous Kirschner wires even when a satisfactory closed reduction has been achieved

The extended lateral L-shaped approach for the treatment of displaced intra-articular fractures of the calcaneum may be complicated by wound infection, haematoma, dehiscence and injury to the sural nerve. In an effort to reduce the risk of problems with wound healing a technique was developed that combined open reduction and fixation of the joint fragments and of the anterior process with percutaneous reduction and screw fixation of the tuberosity. A group of 24 patients with unilateral isolated closed Sanders type II and III fractures was treated using this technique and compared to a similar group of 26 patients managed by the extended approach and lateral plating. The operation was significantly shorter (p < 0.001) in the first group, but more minor secondary procedures and removal of heel screws were necessary. There were no wound complications in this group, whereas four minor complications occurred in the second group. The accuracy and maintenance of reduction, and ultimate function were equivalent

Paget's disease of bone (PDB) is the second most common metabolic bone disease. Osteoarthritis (OA) affects one-third of patients with PDB. The incidence of THR (total hip replacement) and TKR (total knee replacement) is 3.1- and 1.7-fold higher in PDB patients compared to non-affected age-matched controls. No large studies or joint registry reports exist describing the outcomes following THR or TKR in patients with PDB. The objectives of this study were to investigate the outcomes following THR and TKR in patients with PDB using national joint registry data. 144 THR and 43 TKR were identified using the Scottish Arthroplasty Project from 1996–2013. For THR, the most common early post-operative surgical complications were haematoma formation (1.4%), and surgical site infection (1.4%). The absolute incidence during follow-up of dislocation was 2.8%, and revision hip arthroplasty was performed in 2.8% of cases. Implant survival of the primary prosthesis was 96.3% (CI: 92.8 – 99.8) at 10-years, and patient survival was 50.0% (39.6 – 60.4) at 10-years. For TKR, the most common early post-operative surgical complication was surgical site infection (2.3%). The absolute incidence during follow-up of revision knee arthroplasty was 4.7%. On survival analysis, implant survival of the primary prosthesis was 94.5% (CI: 87.1 – 100) at 10-years, and patient survival was 38.3% (16.7 – 59.9) at 10-years. This is the largest reported series of outcomes following primary THR and TKR in patients with PDB. PDB patients are not at increased risk of surgical complications following primary THR or TKR compared to non-PDB patients

Introduction. Parathyroid hormone 1–34 (PTH) has been reported to accelerate fracture healing. Previously, we demonstrated human fracture hematoma contained osteo-/chondro-progenitor cells. To date, there has been no study investigating the effect of PTH on fracture hematoma-derived cells (HCs) in vitro. Hypothesis. We hypothesized PTH treatment affected osteogenesis and chondrogenesis of HCs. Materials & Methods. HCs were divided into 3 groups: control (growth medium), PTH (−) (osteogenic or chondrogenic medium (OM or CM)), and PTH (+) group (OM or CM with PTH). Cell proliferation was assessed by MTS assay. Osteogenesis was assessed by alkaline phosphatase (ALP) activity, real-time PCR, and Alizarin red S staining. Chondrogenesis was assessed by real-time PCR and Safranin-O staining. Results. There was no significant difference in proliferation among 3 groups. ALP activity and expression levels of ALP and Runx2 in PTH (+) group were comparable with PTH (−) group. HCs in PTH (−) and PTH (+) group were strongly stained with Alizarin red S staining. The expression levels of collagen-II and -X in PTH (+) group were significantly lower than PTH (−) group. Pellets in PTH (+) group were slightly stained with Safranin-O staining. Discussion & Conclusion. Our results revealed that PTH treatment did not affect osteogenesis and inhibited chondrogenesis of HCs. PTH treatment after fracture may positively affect other cells such as periosteum-derived cells and circulating stem cells

Aims

The aim of this study to compare 30-day survival and recovery of mobility between patients mobilized early (on the day of, or day after surgery for a hip fracture) and patients mobilized late (two days or more after surgery), and to determine whether the presence of dementia influences the association between the timing of mobilization, 30-day survival, and recovery.