We report a case of fatal heart failure caused by cobalt intoxication after revision THR in the patient who successfully underwent re-revision THR. 53-year old male presented to emergency room in our hospital with progressive shortness of breath. Symptom was started about 6 months ago so he visited local hospital. He worked up for worsening dyspnea. Simple chest radiograph and enhanced heart MRI study were performed and they showed bilateral pericardial and pleural effusion. There was no evidence of ischemic change. Transthoracic echocardiogram showed the evidence of heart failure, left ventricular ejection fraction(EF) was 40%. He was admitted at local hospital and started on vasopressors but urine output was decreased and follow-up echocardiogram showed a 25% of EF. Patient recommended heart transplantation and transferred our hospital emergency room. He underwent sequential bilateral total hip arthroplasties using CoP bearing surfaces. At 12 years postoperatively, he presented to the other hospital with acute onset of left hip pain. He was diagnosed ceramic head fracture on his left hip. Head and liner change revision surgery was performed using Cobalt-Chrome alloy 28mm metal head and Protruded cross-linked polyethylene liners. In our hospital, the patient admitted cardiovascular department of internal medicine. Patient complained nonspecific fatigue and general weakness but had no other symptoms such as visual and hearing loss, cognitive dysfuction. During work-up, patient presented progressive left hip pain and complaint of discomfort for the mass on the left groin. He also complained Left leg weakness and numbness. Simple radiograph and enhanced CT study was done. Simple radiograph image shows radiodense area around the hip joint and radiologist suspected heterotopic ossification. The cardiovascular department consulted orthopedic department. In the image findings showed huge mass combined hemorrhagic component lining acetabular component extending psoas compartment and eccentric wear on cobalt-chrome alloy metal head. Also highly radiodense material was seen around neck inferor portion and severly deformed metal head was seen. It was highly suspected that metal related granuloma, which means severe metallosis. Performed heavy metals screen, cobalt levels were 397,800 μg/Land chrome levels were 236,000 μg/L suggesting cobalt toxicity. Hip joint aspiration was done for decompression as radiologic intervention and EDTA (ethylenediamine tetraacetate) chelation therapy started immediately. After 10 cycle chelating therapy, metal level was lowered cobalt levels by 255.2μg/L and chrome levels by 39.5 μg/L. When hospital day after 134, Medical condition of the patient was getting improved, we underwent revision surgery using ceramic on ceramic bearing surface. The patient discharged postoperative 79 days. Final heavy metals screen results were 27.79μg/L on cobalt and 22.17μg/L on chrome. Although there were also reported a good clinical result of revision surgery using MoP bearing, and some surgeons reluctant to use CoC articulation because of concerns about re-fracture of ceramic. But take into account like this devastating complication after cobalt-chrome wear caused by remained ceramic particles, we should carefully select which bearing is safer

Aims. Medical comorbidities are a critical factor in the decision-making process for operative management and risk-stratification. The Hierarchical Condition Categories (HCC) risk adjustment model is a powerful measure of illness severity for patients treated by surgeons. The HCC is utilized by Medicare to predict medical expenditure risk and to reimburse physicians accordingly. HCC weighs comorbidities differently to calculate risk. This study determines the prevalence of medical comorbidities and the average HCC score in Medicare patients being evaluated by neurosurgeons and orthopaedic surgeon, as well as a subset of academic spine surgeons within both specialities, in the USA. Methods. The Medicare Provider Utilization and Payment Database, which is based on data from the Centers for Medicare and Medicaid Services’ National Claims History Standard Analytic Files, was analyzed for this study. Every surgeon who submitted a valid Medicare Part B non-institutional claim during the 2013 calendar year was included in this study. This database was queried for medical comorbidities and HCC scores of each patient who had, at minimum, a single office visit with a surgeon. This data included 21,204 orthopaedic surgeons and 4,372 neurosurgeons across 54 states/territories in the USA. Results. Orthopaedic surgeons evaluated patients with a mean HCC of 1.21, while neurosurgeons evaluated patients with a mean HCC of 1.34 (p < 0.05). The rates of specific comorbidities in patients seen by orthopaedic surgeons/neurosurgeons is as follows: Ischemic heart disease (35%/39%), diabetes (31%/33%), depression (23%/31%), chronic kidney disease (19%/23%), and heart failure (17%/19%). Conclusion. Nationally, comorbidity rate and HCC value for these Medicare patients are higher than national averages for the US population, with ischemic heart disease being six-times higher, diabetes two-times higher, depression three- to four-times higher, chronic kidney disease three-times higher, and heart failure nine-times higher among patients evaluated by orthopaedic surgeons and neurosurgeons. Cite this article: Bone Joint Open 2020;1-6:257–260

Aims. This study aimed to investigate the risk of postoperative complications in COVID-19-positive patients undergoing common orthopaedic procedures. Methods. Using the National Surgical Quality Improvement Programme (NSQIP) database, patients who underwent common orthopaedic surgery procedures from 1 January to 31 December 2021 were extracted. Patient preoperative COVID-19 status, demographics, comorbidities, type of surgery, and postoperative complications were analyzed. Propensity score matching was conducted between COVID-19-positive and -negative patients. Multivariable regression was then performed to identify both patient and provider risk factors independently associated with the occurrence of 30-day postoperative adverse events. Results. Of 194,121 included patients, 740 (0.38%) were identified to be COVID-19-positive. Comparison of comorbidities demonstrated that COVID-19-positive patients had higher rates of diabetes, heart failure, and pulmonary disease. After propensity matching and controlling for all preoperative variables, multivariable analysis found that COVID-19-positive patients were at increased risk of several postoperative complications, including: any adverse event, major adverse event, minor adverse event, death, venous thromboembolism, and pneumonia. COVID-19-positive patients undergoing hip/knee arthroplasty and trauma surgery were at increased risk of 30-day adverse events. Conclusion. COVID-19-positive patients undergoing orthopaedic surgery had increased odds of many 30-day postoperative complications, with hip/knee arthroplasty and trauma surgery being the most high-risk procedures. These data reinforce prior literature demonstrating increased risk of venous thromboembolic events in the acute postoperative period. Clinicians caring for patients undergoing orthopaedic procedures should be mindful of these increased risks, and attempt to improve patient care during the ongoing global pandemic. Cite this article: Bone Jt Open 2023;4(9):704–712

Aim. Ankle fracture surgery comes with a risk of fracture-related infection (FRI). Identifying risk factors are important in preoperative planning, in management of patients, and for information to the individual patient about their risk of complications. In addition, modifiable factors can be addressed prior to surgery. The aim of the current paper was to identify risk factors for FRI in patients operated for ankle fractures. Method. A cohort of 1004 patients surgically treated for ankle fractures at Haukeland University hospital in the period of 2015–2019 was studied retrospectively. Patient charts and radiographs were assessed for the diagnosis of FRI. Binary logistic regression was used in analyses of risk factors. Regression coefficients were used to calculate the probability for FRI based on the patients’ age and presence of one or more risk factors. Results. FRI was confirmed in 87 (9%) of 1004 patients. Higher age at operation (p < 0.001), congestive heart failure (CHF), p = 0.006), peripheral artery disease (PAD, p = 0.001), and current smoking (p = .006) were identified as risk factors for FRI. PAD and CHF were the risk factors displaying the strongest association with FRI with an adjusted odds ratio of 4.2 (95% CI 1.8–10.1) and 4.7 (95% CI 1.6–14.1) respectively. Conclusions. The prevalence of FRI was 9% after surgical treatment of ankle fractures. The combination of risk factors found in this study demonstrate the need for a thorough, multidisciplinary, and careful approach when faced with an elderly or frail patient with an ankle fracture. The results of this study help the treating surgeons to inform their patients of the risk of FRI prior to ankle fracture surgery

Introduction. Open fractures are fortunately rare but pose an even greater challenge due to poor soft tissues, in addition to poor bone quality. Co-morbidities and pre-existing medical conditions, in particular, peripheral vascular diseases make them often unsuitable for free flaps. We present our experience in treating severe open fractures of tibia with Acute Intentional Deformation (AID) to close the soft tissues followed by gradual correction of deformity to achieve anatomical alignment of the tibia and fracture healing with Taylor Spatial Frame. Materials and Methods. We treated 4 geriatric (3 female and 1 male) patients with Gustillo-Anderson III B fractures of the tibia between 2017–18. All were unfit to undergo orthoplastic procedures (free flap or local flaps). The age range is 69 yrs to 92 years. Co-morbidities included severe rheumatoid arthritis, multiple sclerosis and heart failure. The procedure involved wound debridement, application of two ring Taylor Spatial Frame, acute deformation of the limb on the table to achieve soft-tissue closure/approximation. Regular neurovascular assessments were performed in the immediate post-operative period to monitor for compartment syndrome and nerve compression symptoms. After 7–10 days of latent period, the frame was gradually manipulated, according to a method we had previously published, to achieve anatomical alignment. The frame was removed in clinic after fracture healing. Results. Time in frame ranged from 1.5 months to 7 months. In one patient (92 yr old with an open fracture of the ankle) hindfoot nail was inserted after soft-tissue closure was achieved at 1.5 months, and frame removed. We achieved complete healing of soft tissue wounds without any input from plastic surgeons in all patients. All fractures healed in anatomical alignment. 3 patients had one episode of superficial pin infection each requiring 5 days of oral antibiotics. None of the patients developed a deep infection. Conclusions. Acute intentional deformation (AID) with Taylor Spatial Frame achieves good closure of soft tissues in physiologically compromised geriatric patients who were deemed unfit for plastic surgery. We also achieved fracture healing in all four cases without any major complications

Hip fractures are a common cause of morbidity and mortality in the elderly, with approximately 30,000 hip fractures a year in Canada. Many hip fracture patients are prone to heart failure and present anticoagulated with Warfarin for medical comorbidities including atrial fibrillation or previous thromboembolic disease. Reversal of warfarin anticoagulation to an INR < 1.5 preferred for surgery but this often contributes to a delay to hip fracture surgery, which increases patient pain, morbidity, mortality, and length of stay Octaplex is a small-volume prothrombin complex concentrate (PCC) that reverses Warfarin-related anticoagulation in 15–60 minutes. It has been shown to be safe and effective in the management of intracranial and gastrointestinal bleeding in warfarinised patients. It is recommended by Bone and Joint Canada as an option for urgent warfarin reversal in hip fracture patients. However, there has been no published literature on the use of Octaplex or other PCCs in orthopaedic patients. Our objective is to assess the effectiveness of Octaplex for rapid reversal of warfarin anticoagulation in hip fracture patients. A database review of all patients who received Octaplex was performed. Medical records of all hip fracture patients in Calgary who received Octaplex between December 2009 and February 2015 were reviewed. After application of inclusion and exclusion criteria, 33 patients were identified. A timeline of International Normalised Ratio (INR), Octaplex administration, and hip fracture surgery was recorded. Mortality and complications were assessed at 30 days. A single dose of Octaplex corrected the INR to < 1.5 in 29 cases (88%). Median time from administration of Octaplex to a measured INR < 1.5 was 1.1 hours. Median time from admission to hip fracture surgery was 22 hours. Mortality at 30 days was 15.2%, mostly from cardiac arrest. A further 12% of patients developed cardiac or thrombotic complications. Multiple medical comorbidities were common including coronary artery disease (55%), congestive heart failure (45%), and chronic pulmonary disease (39%). Patients who received both fresh frozen plasma (FFP) and Octaplex for warfarin reversal had much higher mortality than those who only received Octaplex (40% vs 4.3% mortality at 30 days), but also had more medical comorbidities. Octaplex is effective at rapidly reversing warfarin anticoagulation and reducing time to surgery, potentially reducing the morbidity and mortality of hip fractures. Administration of both Octaplex and FFP were associated with higher early mortality in this case series. Further research is required to assess the safety of Octaplex, vitamin K, and FFP for reversal of warfarin anticoagulation in this population

Currently 180 days is the target maximum wait time set by all Canadian provinces for elective joint replacement surgery. In Nova Scotia however, only 34% of Total Knee Arthroplasties (TKA) and 51% of Total Hip Arthroplasties (THA) met this benchmark in 2017. Surgery performed later in the natural history of disease is shown to have significant impact on pain, function and Health related Quality of Life at the time of surgery and potentially affect post-operative outcomes. The aim of this study is to describe the association between wait time and acute hospital Length of Stay (LOS) during elective hip and knee arthroplasty in province of Nova Scotia. Secondarily we aim to describe risk factors associated with variations in LOS. Data from Patient Access Registry Nova Scotia (PAR-NS) was linked to the hospital Discharge Access Database (DAD) for primary hip and knee arthroplasty spanning 2009 to 2017. There were 23,727 DAD observations and 21,329 PARNS observations identified. Observations were excluded based on missing variables, missing linkages, revision status and emergency cases. Percentage difference in LOS, risk factors and outcomes were analyzed using Poisson regression for those waiting more than 180 days compared to those waiting equal or less than 180 days. For primary TKA, 11,833 observations were identified with mean age of 66 years, mean wait time of 348 days and mean LOS of 3.6 days. After adjusting for controls, patients waiting more than 180 days for elective TKA have a 2.5% longer acute care LOS (p < 0.028). Risk factors identified for prolonged LOS are advanced age, female gender, higher surgical priority indicator, required blood transfusion, dementia, peptic ulcer disease, cerebrovascular disease, heart failure, chronic kidney disease, malignancy, ischemic heart disease and diabetes. Factors associated with decreased LOS are surgical year, use of local anesthetic, peripheral location of hospital and admission to hospital from home. For primary THA, 6626 observations were identified with mean age of 66 years, mean wait time of 267 days and mean LOS of 4 days. Patients waiting more than 180 days for THA did not show a statistically significant association with LOS. Risk factors and protective factors are the same with exception of CVD and use of local anesthetic. Our findings suggest a positive and statistically significant association for patients waiting more than 180 days for TKA and longer acute care LOS. Longer LOS may be due to deteriorating health status while placed on a surgical waitlist and may represent a delayed and indirect cost to the patient and the healthcare system. Ultimately with projected increase in demand for elective joint replacement surgeries, our findings are aimed to inform physicians and policy makers in management of surgical waitlist efficiency and cost effectiveness. For any reader inquiries, please contact . shahriar-s@hotmail.com

Recent studies have described safe outcomes for short-stays in the hospital after total shoulder arthroplasty. The purpose of this study is to identify pre-operative and operative risk factors for hospital admissions exceeding 24 hours. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried from 2006 to 2016 for the current procedural terminology (CPT) billing code related to total shoulder arthroplasty. Patients were then grouped as either having a length of stay (LOS) equal to or less than 24 hours or greater than 24 hours. Patients admitted to the hospital prior to the day of surgery were excluded. Patient demographics, co-morbidities, and operative time were then analyzed as risk factors for a hospital stay exceeding 24 hours. Pre-operative co-morbidities included body mass index (BMI), diabetes, smoking, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hypertension, dialysis, chronic steroid or immunosuppressant use, bleeding disorders, and American Society of Anesthesiologists (ASA) Classification. Univariate and multivariate analyses were then performed to identify risk factors associated with 30-day readmission. 14,339 patients met inclusion criteria and 6,507 (45.3%) had a hospital LOS less than or equal to 24 hours. The mean length of hospitalization was 1.95 ± 1.88 days, the average age was 69 ± 9.7 years old, and 56.9% of the patients were female. Following a risk adjusted multivariate analysis, increasing age (odds ratio [OR], 1.03, 95% confidence interval [CI], 1.02–1.03), ASA classification (OR, 1.50, 95% CI, 1.41–1.60), diabetes (OR, 1.69, 95% CI, 1.43–1.99), COPD (OR, 1.35, 95% CI, 1.16–1.57), CHF (OR, 2.67, 95% CI, 1.34–5.33), dialysis (OR, 2.47, 95% CI, 1.28, 4.77), history of a bleeding disorder (OR, 1.50, 95% CI, 1.20–1.88), or increasing operative time (OR, 1.01, 95% CI, 1.01–1.01) were identified as independent risk factors for hospital lengths of stay exceeding 24 hours. Male gender was identified as a protective factor for prolonged hospitalization (OR, 0.50, 95% CI, 0.46–0.53). This study identifies patient demographics, co-morbidities, and operative-relative risk factors that are associated with increased risk for a prolonged hospitalization following total shoulder arthroplasty. Female gender, increasing age, ASA classification, operative time, or a history of diabetes, COPD, CHF, or history of a bleeding disorder are risk factors hospitalizations exceeding 24 hours

Over 300,000 total hip arthroplasties (THA) are performed annually in the USA. Surgical Site Infections (SSI) are one of the most common complications and are associated with increased morbidity, mortality and cost. Risk factors for SSI include obesity, diabetes and smoking, but few studies have reported on the predictive value of pre-operative blood markers for SSI. The purpose of this study was to create a clinical prediction model for acute SSI (classified as either superficial, deep and overall) within 30 days of THA based on commonly ordered pre-operative lab markers and using data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. All adult patients undergoing an elective unilateral THA for osteoarthritis from 2011–2016 were identified from the NSQIP database using Current Procedural Terminology (CPT) codes. Patients with active or chronic, local or systemic infection/sepsis or disseminated cancer were excluded. Multivariate logistic regression was used to determine coefficients, with manual stepwise reduction. Receiver Operating Characteristic (ROC) curves were also graphed. The SSI prediction model included the following covariates: body mass index (BMI) and sex, comorbidities such as congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), smoking, current/previous steroid use, as well as pre-operative blood markers, albumin, alkaline phosphate, blood urea nitrogen (BUN), creatinine, hematocrit, international normalized ratio (INR), platelets, prothrombin time (PT), sodium and white blood cell (WBC) levels. Since the data met logistic assumption requirements, bootstrap estimation was used to measure internal validity. The area under the ROC curve for final derivations along with McFadden's R-squared were utilized to compare prediction models. A total of 130,619 patients were included with the median age of patients at time of THA was 67 years (mean=66.6+11.6 years) with 44.8% (n=58,757) being male. A total of 1,561 (1.20%) patients had a superficial or deep SSI (overall SSI). Of all SSI, 45.1% (n=704) had a deep SSI and 55.4% (n=865) had a superficial SSI. The incidence of SSI occurring annually decreased from 1.44% in 2011 to 1.16% in 2016. Area under the ROC curve for the SSI prediction model was 0.79 and 0.78 for deep and superficial SSI, respectively and 0.71 for overall SSI. CHF had the largest effect size (Odds Ratio(OR)=2.88, 95% Confidence Interval (95%CI): 1.56 – 5.32) for overall SSI risk. Albumin (OR=0.44, 95% CI: 0.37 – 0.52, OR=0.31, 95% CI: 0.25 – 0.39, OR=0.48, 95% CI: 0.41 – 0.58) and sodium (OR=0.95, 95% CI: 0.93 – 0.97, OR=0.94, 95% CI: 0.91 – 0.97, OR=0.95, 95% CI: 0.93 – 0.98) levels were consistently significant in all clinical prediction models for superficial, deep and overall SSI, respectively. In terms of pre-operative blood markers, hypoalbuminemia and hyponatremia are both significant risk factors for superficial, deep and overall SSI. In this large NSQIP database study, we were able to create an SSI prediction model and identify risk factors for predicting acute superficial, deep and overall SSI after THA. To our knowledge, this is the first clinical model whereby pre-operative hyponatremia (in addition to hypoalbuminemia) levels have been predictive of SSI after THA. Although the model remains without external validation, it is a vital starting point for developing a risk prediction model for SSI and can help physicians mitigate risk factors for acute SSI post THA

Total knee arthroplasty (TKA) is the most commonly performed elective orthopaedic procedure. With an increasingly aging population, the number of TKAs performed is expected to be ∼2,900 per 100,000 by 2050. Surgical Site Infections (SSI) after TKA can have significant morbidity and mortality. The purpose of this study was to construct a risk prediction model for acute SSI (classified as either superficial, deep and overall) within 30 days of a TKA based on commonly ordered pre-operative blood markers and using audited administrative data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. All adult patients undergoing an elective unilateral TKA for osteoarthritis from 2011–2016 were identified from the NSQIP database using Current Procedural Terminology (CPT) codes. Patients with active or chronic, local or systemic infection/sepsis or disseminated cancer were excluded. Multivariate logistic regression was conducted to estimate coefficients, with manual stepwise reduction to construct models. Bootstrap estimation was administered to measure internal validity. The SSI prediction model included the following co-variates: body mass index (BMI) and sex, comorbidities such as congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), smoking, current/previous steroid use, as well as pre-operative blood markers, albumin, alkaline phosphatase, blood urea nitrogen (BUN), creatinine, hematocrit, international normalized ratio (INR), platelets, prothrombin time (PT), sodium and white blood cell (WBC) levels. To compare clinical models, areas under the receiver operating characteristic (ROC) curves and McFadden's R-squared values were reported. The total number of patients undergoing TKA were 210,524 with a median age of 67 years (mean age of 66.6 + 9.6 years) and the majority being females (61.9%, N=130,314). A total of 1,674 patients (0.8%) had a SSI within 30 days of the index TKA, of which N=546 patients (33.2%) had a deep SSI and N=1,128 patients (67.4%) had a superficial SSI. The annual incidence rate of overall SSI decreased from 1.60% in 2011 to 0.68% in 2016. The final risk prediction model for SSI contained, smoking (OR=1.69, 95% CI: 1.31 – 2.18), previous/current steroid use (OR=1.66, 95% CI: 1.23 – 2.23), as well as the pre-operative lab markers, albumin (OR=0.46, 95% CI: 0.37 – 0.56), blood urea nitrogen (BUN, OR=1.01, 95% CI: 1 – 1.02), international normalized ratio (INR, OR=1.22, 95% CI:1.05 – 1.41), and sodium levels (OR=0.94, 95% CI: 0.91 – 0.98;). Area under the ROC curve for the final model of overall SSI was 0.64. Models for deep and superficial SSI had ROC areas of 0.68 and 0.63, respectively. Albumin (OR=0.46, 95% CI: 0.37 – 0.56, OR=0.33, 95% CI: 0.27 – 0.40, OR=0.75, 95% CI: 0.59 – 0.95) and sodium levels (OR=0.94, 95% CI: 0.91 – 0.98, OR=0.96, 95% CI: 0.93 – 0.99, OR=0.97, 95% CI: 0.96 – 0.99) levels were consistently significant in all prediction models for superficial, deep and overall SSI, respectively. Overall, hypoalbuminemia and hyponatremia are both significant risk factors for superficial, deep and overall SSI. To our knowledge, this is the first prediction model for acute SSI post TKA whereby hyponatremia (and hypoalbuminemia) are predictive of SSI. This prediction model can help fill an important gap for predicting risk factors for SSI after TKA and can help physicians better optimize patients prior to TKA

Aim. Orthopedic implant related surgical site infection (SSI) is a severe complication which represents an important challenge concerning to its treatment. Therefore, gram-negative orthopedic infections have recently become a global concern. Method. Retrospective study through searching of the SCIH (infection control service) database, concerning to the year 2016 and 2017. Cases selected were those of implant placement clean surgeries (osteosynthesis or prosthetic placement) which evolved with SSI and Gram-negative bacterial growth in bone tissue or periprosthetic cultures. Results. During 2016 and 2017, 6150 clean surgeries with orthopedic implant placement were performed; 140 fulfilled SSI criteria (83 cases of open fracture reduction, 44 of hip arthroplasty, 13 of knee arthroplasty). Main agent of infections was Staphylococcus aureus (32,47%) mostly of them methicillin-sensitive (69,20%). However, Gram-negative bacteria were responsible for 64,95% of infections. (Klebsiella pneumoniae 12.8%; Acinetobacter baumannii and Enterobacter ssp 11.96%; Pseudomonas aeruginosa 9.40%) Among them, 100% Enterobacter ssp. were sensitive to carbapenems and 75% to ciprofloxacin. Klebsiella pneumoniae showed sensitivity to carbapenems in 85.7%, Pseudomonas aeruginosa showed sensitivity in 85.7% to carbapenems and 100% to ciprofloxacin. Acinetobacter baumannii showed the least favorable profile amongst Gram-negatives since only 12.5% of strains were sensitive to carbapenems, 28.6% to Ampicilin-sulbactam, 22.2% to ciprofloxacin, while showing 100% sensitivity to polymyxins. 14 patients in whom Acinetobacter baumannii was isolated were predominantly elderly (median 70 years), most of them have underlying/chronic diseases (71.42%) such as diabetes, arterial hypertension, alcoholism, smoking and heart failure. None presented sepsis related to this infection, but four of them died as result of hospitalization related complications (28,60% mortality rate). Among these deaths, 3 were related to total hip arthroplasty, and one to knee arthroplasty. One patient died as result of external causes. Among the survivors, five showed remission/cure. The follow up was lost in 4 patients. Conclusions. SSI caused by carbepenem-resistant Acinetobacter baumannii represents considerable impact on morbi-mortality in patients who undergo surgery with placement of orthopedic implants

Aim. The optimal treatment of streptococcal prosthetic joint infections (PJIs) is unclear. Poorer outcome has been associated with Streptococcus agalactiae species, comorbidities and polyethylene exchange for conservative approach. Rifampicin use may be associated with higher remission rate but results are sparse. Method. A cohort of streptococcal PJI (including total hip arthroplasty –THA- or total knee arthroplasty –TKA-) was prospectively created and retrospectively reviewed in 7 reference centers for management of complex PJI between January 1, 2010 and December 31, 2012. Results. Seventy patients (47 infections of THA and 23 infections of total TKA) with monomicrobial infections were included. Median age was 77 (interquartile range [IQR] [69 – 83], 15.6% (n=11) had diabetes, median Charlson comorbidity score was 4 [3 – 6] and 31.4% (n=22) had chronic heart failure. Streptococcus agalactiae and S. dysgalactiae were the most commonly streptococcal species found, in 38.6% (n=27) and 17.1% (n=12) of cases respectively. Debridement, antibiotic and implant retention (DAIR) was performed after a median time of 7 days [3 – 8] with polyethylene exchange (PE) performed in 21% of these treatments. After a median follow-up of 22 month [12 – 31], 27% of patients relapsed corresponding to 51.4% of DAIR treatment and 0% of one- (n=15) or two-stage exchange strategy (n=17). Rifampicin or levofloxacin combination were not associated with a better outcome (p=0.82 and p=1, respectively). A shorter intravenous antimicrobial therapy, a S. agalactiae species and DAIR treatment were associated with a higher risk of failure. In multivariate analysis, only DAIR treatment and S. agalactiae were independent factors of relapse. PE was associated with a trend toward benefit (odds ratio 0.26 [95% CI: 0.021 – 1.98; p=0.26]) but did not reach statistical significance. Conclusions. Streptococcal PJIs managed with DAIR have a poor prognosis and S. agalactiae seems to be an independent factor of failure

Venous thromboembolism (VTE) prophylaxis following total joint arthroplasty (TJA) should be individualised in order to maximise the efficacy of prophylactic measures while avoiding the adverse events associated with the use of anticoagulants. At our institution, we have developed a scoring model using the Nationwide Inpatient Sample (NIS) database, which is validated against our institutional data, to stratify patients into low- and high-risk groups for VTE. Low-risk patients are placed on aspirin 81 mg twice daily for four weeks post-operatively, and high-risk patients are placed on either a Vitamin K antagonist (warfarin), low molecular weight heparin, or other oral anticoagulants for four weeks post-operatively. All patients receive sequential pneumatic compression devices post-operatively, and patients are mobilised with physical therapy on the day of surgery. Patients who have a history of peptic ulcer disease or allergy to aspirin are also considered for other types of anticoagulation following surgery. Risk Stratification Criteria. Major comorbid risk factors utilised in our risk stratification model include history of hypercoagulability or previous VTE, active cancer or history of non-cutaneous malignancy, history of stroke, and pulmonary hypertension. We consider patients with any of these risk factors at elevated risk of VTE and therefore candidates for formal anticoagulation. Other minor risk factors include older age, bilateral surgery compared with unilateral, inflammatory bowel disease, varicose veins, obstructive sleep apnea, and history of myocardial infarction, myeloproliferative disorders, and congestive heart failure. Each minor criterion is associated with a score. The cumulative score is compared with a defined threshold and the score that surpasses the threshold indicates that the patient should receive post-operative anticoagulation. To facilitate the use of this scoring system, an iOS mobile application (VTEstimator) has been developed and can be downloaded from the app store

Acetabular reconstruction with impaction bone grafting and a cemented polyethylene aims to reconstitute the bone stock in hip revision. This is an effective but expensive, resource intensive and time consuming technique. Most surgeons remove the articular cartilage from the femoral head allograft. The aim of this study is to reproduce the results using the whole femoral head with the articular cartilage for acetabular impaction grafting. 38 acetabular revisions using impacted morselised bone graft retaining the articular cartilage and a cemented cup were studied retrospectively. The operations were performed by the senior author in Wrightington Hospital, UK with a posterior hip approach. The mean follow up was 4.1 years (range, 1–10 years). Clinical and radiological assessment was made using the Oxford hip score, Hodgkinson's criteria (1988) for socket loosening and the Gie classification (1993) for evaluation of allograft incorporation. Thirty-six (94.7%) sockets were considered radiologically stable (type 0, 1, 2 demarcations) and two (5.3%) sockets were radiologically loose (type 3 demarcations) but there was no socket migration. Twenty-one (55.3%) cases showed good trabecular remodeling (grade 3). Fourteen (36.8 %) cases showed trabecular remodeling (grade 2). Only three (7.9%) cases showed poor allograft incorporation (grade 1). Mean pre-operative hip score was 41 and post-operative hip score was 21. There was one (2.6%) wound infection treated with oral antibiotics and one (2.6%) periprosthetic femoral fracture treated with cables. Furthermore, there was one (2.6%) case of pulmonary embolism and three (7.89%) cases of asymptomatic heterotopic ossification. One year mortality rate was 2.6% (one case) from heart failure but not associated with the surgery. There have been no socket re-revisions (100% survival) at an average of 4 years. At a mean follow up of 4 years, results with the aforementioned technique are comparable to other major studies. Compared to the 40% of minimal loss in obtaining pure cancellous graft less than 10% of initial graft mass is lost without removing the articular cartilage. Particularly when the supply of allograft and operative time are limited retaining the articular cartilage of the femoral head is a safe and effective alternative to be considered

To progress to a same day surgery program for arthroplasty, it is important that we examine and resolve the issues of why patients stay in the hospital. The number one reason is fear and anxiety of the unknown and of surgical pain. The need for hospital stay is also related to risk arising from comorbidities and medical complications. Patients also need an extended stay to manage the side effects of our treatment, including after effects of narcotics and anaesthesia, blood loss, and surgical trauma. The process begins pre-operatively with an appropriate orthopaedic assessment of the patient and determination of the need for surgery. The orthopaedic team must motivate the patient, and ensure that the expectations of the patient, family and surgeon are aligned. In conjunction with our affiliated hospitalist group that performs almost all pre-admission testing, we have established guidelines for patient selection for outpatient arthroplasty. The outpatient surgical candidate must have failed conservative measures, must have appropriate insurance coverage, and must be functionally independent. Previous or ongoing comorbidities that cannot be optimised for safe outpatient care may include: congestive heart failure, or valve disease; chronic obstructive pulmonary disease, or home use of supplemental oxygen; untreated obstructive sleep apnea with a BMI >40 kg/m2; hemodialysis or severely elevated serum creatinine; anemia with hemoglobin <13.0 g/dl; cerebrovascular accident or history of delirium or dementia; and solid organ transplant. Pre-arthroplasty rehabilitation prepares the patient for peri-operative protocols. Patients meet with a physical therapist and are provided with extensive educational materials before surgery to learn the exercises they will need for functional recovery. Enhancement of our peri-operative pain management protocols has resulted in accelerated rehabilitation. The operative intervention must be smooth and efficient, but not hurried. Less invasive approaches and techniques have been shown to decrease pain, reduce length of stay, and improve outcomes, especially in the short term. Between June 2013 and December 2015, 1957 primary knee arthroplasty procedures (1010 total, 947 partial) were performed by the author and his 3 associates at an outpatient surgery center. Seven percent of patients required an overnight stay, with a majority for reasons of convenience related to travel distance or later operative time. Importantly, no one has required overnight stay for pain management. Outpatient arthroplasty is safe, it's better for us and our patients, and it is here now. In an outpatient environment the surgeon actually spends more time with the patients and family in a friendly environment. Patients feel safe and well cared for, and are highly satisfied with their arthroplasty experience

Periprosthetic joint infection (PJI) is one of the most devastating complications of total joint arthroplasty (TJA). Only a few studies have investigated PJI's impact on the most worrisome of all endpoints, mortality. The purpose of this study was to perform a large-scale study to determine the rates of PJI associated in-hospital mortality, and compare it to other surgical procedures. The Nationwide Inpatient Sample was queried from 2002 to 2010 to assess the risk of mortality for patients undergoing revision for PJI or aseptic failures. Elixhauser comorbidity index and ICD-9 codes were used to obtain patients’ medical conditions and identify PJI. Multiple logistic-regression analyses were used to determine the associated variables with mortality. In-hospital mortality was compared to the followings: coronary-artery bypass graft, mastectomy, prostatectomy, appendectomy, kidney transplant, carotid surgery, cholecystectomy, and coronary interventional procedures. PJI was associated with an increased risk (odds ratio 2.04) of in-hospital mortality (0.77%) compared to aseptic revisions (0.38%). The in-hospital mortality of revision THAs done for PJI (1.38%, 95%CI, 1.12–1.64%) was comparable to or higher than interventional coronary procedure (1.22%, 95%CI, 1.20–1.24%), cholecystectomy (1.13%, 95%CI, 1.11–1.15%), kidney transplantation (0.70%, 95%CI, 0.61%–0.79%) and carotid surgery (0.89%, 95%CI, 0.86%–0.93%) (Figure 1). The following comorbidities were independent risk factors for in-hospital mortality after TJA: liver disease, metastatic disease, fluid and electrolyte disorders, coagulopathy, weight loss and malnutrition, congestive heart failure, pulmonary circulation disorder, renal failure, and peripheral vascular disease. PJI is associated with a two-fold increase in mortality and have mortality rates comparable to kidney transplantation and carotid surgery. Considering the fact that patients with PJI often require multiple surgical procedures, the rate of actual in-hospital mortality for patients with PJI may be considerably higher. Surgeons should be cognizant of the potentially fatal outcome of PJI and must emphasize the importance of infection control to reduce the risk of mortality

Posttraumatic osteomyelitis (PTO) is a complex condition that results in considerable morbidity. Tibia is one of the most common sites of PTO, with an average infection rate of 10% for open fractures and 1% for closed fractures. In most cases osteomyelitis is polymicrobial. Staphylococcus aureus is the most common infecting organism present either alone or in combination with other pathogens in 65 to 70% of patients. Developments in surgery have greatly improved the ability to treat this condition. However, some authors defend that functional outcome is often poorer after successful limb reconstruction than after treatment with amputation below the knee, especially in patients with systemic factors that might significantly compromise reconstructive treatment. Limb salvage is associated with a longer convalescence time and a higher risk of complications, additional surgeries, and rehospitalisation. We present a case report of a patient with PTO requiring amputation of the leg despite aggressive surgical treatment. The authors present a case of an 86-year-old woman with past medical history significant for diabetes, hypertension, severe peripheral artery disease and congestive heart failure. In March 2013 the patient sustained a tibia and fibula fracture (42-C1 AO Classification). Closed reduction and intramedullary nailing were performed. Osteomyelitis was diagnosed 1 month later. Implant removal, debridement, stabilization with external fixator and a vascularized skin graft were performed. Graft necrosis with bone exposure occurred after 1 month. Cultures were positive for multiple pathogens, including methicillin-sensitive Staphylococcus aureus. Several surgical debridement, vacuum-assisted closure therapy (VAC) and specific antibiotic therapy were performed for 8 weeks. Clinical deterioration with persistent bacteremia and infectious process led to the amputation below the knee in October 2014. Symptomatic relieve was achieved and C-reactive protein returned to her normal values. Minimal stump necrosis was detected. Seven months postoperatively the patient is doing well with assisted gaitpilaa and few limitations in her daily life and there are no signs of systemic or local infection. Management of posttraumatic osteomyelitis remains a challenge. Amputation may prove to be the most appropriate way of restoring function and improving patient's quality of live, if there is failure to achieve bone healing and restore function. The decision to amputate should be considered carefully and individually, involving both patient and family

Preoperative antibiotic prophylaxis remains one of the most important strategies for preventing periprosthetic joint infection (PJI). Current guidelines recommend giving universal antibiotic prophylaxis to all total joint arthroplasty (TJA) patients regardless of their medical conditions or immune status. The aims of this study were to determine if comorbidities influence the organism profile of PJIs and to investigate if the efficacy of the two most frequently used perioperative antibiotics (cefazolin or vancomycin) are affected by patient comorbidities. Using an institutional database, the influence of comorbidities on the organism profile of 1022 PJIs was evaluated. To investigate the influence of perioperative antibiotic monotherapy (cefazolin or vancomycin therapy) on PJI, 8575 primary TJAs were identified and analyzed based on their comorbidities. Patients with multiple perioperative antibiotics, prior septic arthritis, unavailable perioperative antibiotic information, or who underwent aseptic revision were excluded. PJI was determined from ICD-9 codes. While no comorbidities were associated with an increased rate of gram-positive or gram-negative infections, metastatic disease (odds ratio [OR] 7.54, p=0.006), rheumatologic disease (OR 1.63, p=0.046), and chronic pulmonary disease (OR 1.46, p=0.030) demonstrated an increased risk of Staphylococcus aureus PJI. In addition, metastatic disease (OR 5.71, 95% confidence interval [CI] 1.12–26.93, p=0.018), congestive heart failure (OR 2.2, 95% CI 1.16–4.00, p=0.010), chronic pulmonary disease (OR 1.76; 95% CI 1.09–2.78, p=0.015), and diabetes (OR 1.66; 95% CI 1.08–2.52, p=0.019) were associated with PJI from antibiotic resistant organisms. However, there was no difference in the rate of PJI between cefazolin and vancomycin monotherapy when stratified for the aforementioned comorbidities. The present study reveals that comorbidities do not significantly alter the organism profile of high-risk comorbidities and that comorbidities associated with immune deficits do not influence the rate of PJI between two different antibiotics. The results of this study thus support current guidelines, which provide a universal recommendation rather than a protocol that is tailored to a patient's preexisting comorbidities

To progress to a same day surgery program for arthroplasty, it is important that we examine and resolve the issues of why patients stay in the hospital. The number one reason is fear and anxiety for the unknown and for surgical pain. The need for hospital stay is also related to risk arising from comorbidities and medical complications. Patients also need an extended stay to manage the side effects of our treatment, including after-effects of narcotics and anesthesia, blood loss, and surgical trauma. The process begins pre-operatively with an appropriate orthopaedic assessment of the patient and determination of the need for surgery. The orthopaedic team must motivate the patient, and ensure that the expectations of the patient, family and surgeon are aligned. In conjunction with our affiliated hospitalist group that performs almost all pre-admission testing, we have established guidelines for patient selection for outpatient arthroplasty. The outpatient surgical candidate must have failed conservative measures, must have appropriate insurance coverage, and must be functionally independent. Previous or ongoing comorbidities that contraindicate the outpatient setting include: cardiac – prior revascularization, congestive heart failure, or valve disease; pulmonary – chronic obstructive pulmonary disease, or home use of supplemental oxygen; untreated obstructive sleep apnea – BMI >40 kg/m2; renal disease – hemodialysis or severely elevated serum creatinine; gastrointestinal – history or post-operative ileus or chronic hepatic disease; genitourinary – history of urinary retention or severe benign prostatic hyperplasia; hematologic – chronic Coumadin use, coagulopathy, anemia with hemoglobin <13.0 g/dl, or thrombophilia; neurological – history of cerebrovascular accident or history of delirium or dementia; solid organ transplant. Pre-arthroplasty rehabilitation prepares the patient for peri-operative protocols. Patients meet with a physical therapist and are provided with extensive educational materials before surgery to learn the exercises they will need for functional recovery. Enhancement of our peri-operative pain management protocols has resulted in accelerated rehabilitation. The operative intervention must be smooth and efficient, but not hurried. Less invasive approaches and techniques have been shown to decrease pain, reduce length of stay, and improve outcomes, especially in the short term. In 2014, 385 primary partial knee arthroplasty procedures (7 patellofemoral replacement, 13 lateral, and 365 medial) were performed by the author and his 3 associates at an outpatient surgery center. Of those, 348 (95%) went home the same day while 17 (5%) required an overnight stay, with 11 for convenience related to travel distance or later operative time and 6 for medical issues. Outpatient arthroplasty is safe, it's better for us and our patients, and it is here now. In an outpatient environment the surgeon actually spends more time with the patients and family in a friendly environment. Patients feel safe and well cared for, and are highly satisfied with their arthroplasty experience

Background. There is a lack of information on the independent preoperative predictors of perioperative mortality, including the influence of previous stroke and acute coronary syndromes (myocardial infarction + unstable angina, ACS). Previous studies have grouped variables under the umbrella term “ischaemic heart disease”. In this study, we investigated the influence of vascular risk factors separately. Methods. The Hospital Episode Statistics database was analyzed for elective admissions for total hip (THR) and total knee (TKR) replacements between 2004 and 2009. Independent preoperative predictors of perioperative outcome were identified from admission secondary diagnosis codes. Perioperative mortality was defined as 30-day in-hospital death. Logistic regression analysis was used to identify independent predictors of 30-day mortality. Data was adjusted for age, social deprivation and Charlson co-morbidity score. Results. 414,985 THRs and TKRs were performed in the study period. There were 829 deaths within 30 days (0.2%). Previous ACS (OR: 1.73 [1.33 to 2.25]) and stroke (OR: 1.64 [1.02 to 2.65]) predicted 30-day mortality. ACS (OR: 3.81 [1.55 to 9.34]) within six months of THKR surgery was associated with increased odds of perioperative mortality. The effect of ACS persisted up to 12 months (OR: 1.99 [1.02 to 3.88]). Renal failure, liver disease, heart failure, peripheral vascular disease and non-atrial fibrillation arrhythmia also increased the odds of mortality. Discussion. Previous stroke and ACS increase the odds of perioperative mortality, together with several other vascular risk factors. Within 12 months of ACS, risk of mortality is significantly elevated. Elective surgery should be avoided in this period