Summary Statement. Navigated total knee arthroplasty (TKA) is becoming increasingly popular in the United States. Compared to traditional unnavigated TKA, the use of navigation is associated with decreased blood transfusions and shorter hospital stays. Introduction. Navigated total knee arthroplasty (TKA) is a recent modification to standard TKA with many purported benefits in regards to component positioning. Controversy currently exists though regarding its clinical benefits. The purpose of this study was to assess recent national trends in navigated and unnavigated total knee arthroplasty and to evaluate perioperative outcomes for each group. Methods. International Classification of Disease - 9th Revision (ICD-9) procedure codes were used to search the National Hospital Discharge Survey (NHDS) for all patients admitted to US hospitals after navigated and unnavigated TKA for each year between 2005 and 2010. Data regarding patient demographics, hospitalization length, discharge disposition, blood transfusions, deep vein thrombosis, pulmonary embolism, mortality, and hospital location were gathered from the NHDS.
Summary Statement. Pulmonary embolism (PE) after total knee arthroplasty can have a significant impact on patient outcomes and healthcare costs. Efforts to prevent or minimise PE over the last 10 years have not had a significant impact on its occurrence at the national level. Introduction. Pulmonary embolism (PE) is a rare but known potentially devastating complication of total knee arthroplasty (TKA). Significant healthcare resources and pharmaceutical research has been recently focused on preventing this complication but limited data exists regarding the early results of this great effort. The purpose of this study was to assess recent national trends in PE occurrence after TKA and evaluate patient outcomes related to this adverse event. Methods. International Classification of Disease - 9th Revision (ICD-9) procedure codes were used to search the National Hospital Discharge Survey (NHDS) for all patients admitted to US hospitals after primary TKA for each year between 2001 and 2010. ICD-9 diagnosis codes were then used to identify patients from this population who developed an acute PE during the same admission. Data regarding patient demographics, hospitalization length, discharge disposition, deep vein thrombosis, mortality, and hospital size/location were gathered from the NHDS.
Summary Statement. Total hip arthroplasty and hemi-arthroplasty are becoming increasingly popular in the treatment of femoral neck fractures in the United States. Both appear to be safe and effective treatment options, with rare acute adverse events and low mortality. Introduction. Femoral neck fractures are one of the most frequent orthopaedic injuries seen in the United States (US). Total hip arthroplasty (THA) and hemiarthroplasty (HA) are commonly used to treat displaced intra-capsular femoral neck fractures, but controversy currently exists regarding the preferred modality. The purpose of this study was to assess recent national trends in THA and HA performed for femoral neck fracture and to evaluate perioperative outcomes for each treatment group. Methods. International Classification of Disease - 9th Revision (ICD-9) diagnosis codes were used to search the National Hospital Discharge Survey (NHDS) for all patients admitted to US hospitals after femoral neck fracture for each year between 2001 and 2010. ICD-9 procedure codes were then used to identify patients from this fracture population who underwent THA or HA. Data regarding patient demographics, hospitalization length, discharge disposition, in-hospital adverse events (pulmonary embolus, deep vein thrombosis, blood transfusion, mortality) and hospital size/location were gathered from the NHDS.
Open limb fractures are typically due to a high energy trauma. Several recent studied have showed treatment's superiority when a multidisciplinary approach is applied. World Health Organization reports that isolate limb traumas have an incidence rate of 11.5/100.000, causing high costs in terms of hospitalization and patient disability. A lack of experience in soft tissue management in orthopaedics and traumatology seems to be the determining factor in the clinical worsening of complex cases. The therapeutic possibilities offered by microsurgery currently permit simultaneous reconstruction of multiple tissues including vessels and nerves, reducing the rate of amputations, recovery time and preventing postoperative complications. Several scoring systems to assess complex limb traumas exist, among them: NISSSA, MESS, AO and Gustilo Anderson. In 2010, a further scoring system was introduced to focus open fractures of all locations: OTA-OFC. Rather than using a single composite score, the OTA-OFC comprises five components grades (skin, arterial, muscle, bone loss and contamination), each rated from mild to severe. The International Consensus Meeting of 2018 on musculoskeletal infections in orthopaedic surgery identified the OTA-OFC score as an efficient catalogue system with interobserver agreement that is comparable or superior to the Gustilo-Anderson classification. OTA-OFC predicts outcomes such as the need for adjuvant treatments or the likelihood of early amputation. An orthoplastic approach reconstruction must pay adequate attention to bone and soft tissue infections management. Concerning bone management: there is little to no difference in terms of infection rates for Gustilo-Anderson types I–II treated by reamed intramedullary nail, circular external fixator, or unreamed intramedullary nail. In Gustilo-Anderson IIIA-B fractures, circular external fixation appears to provide the lowest infection rates when compared to all other fixation methods. Different technique can be used for the reconstruction of bone and soft tissue defects based on each clinical scenario. Open fracture management with fasciocutaneous or muscle flaps shows comparable outcomes in terms of bone healing, soft tissue coverage, acute infection and chronic osteomyelitis prevention. The type of flap should be tailored based on the type of the defect, bone or soft tissue, location, extension and depth of the defect, size of the osseous gap, fracture type, and orthopaedic implantation. Local flaps should be considered in low energy trauma, when skin and soft tissue is not traumatized. In high energy fractures with bone exposure, muscle flaps may offer a more reliable reconstruction with fewer flap failures and lower reoperation rates. On exposed fractures several studies report precise timing for a proper reconstruction. Hence, timing of soft tissue coverage is a critical for length of in-hospital stay and most of the early postoperative complications and outcomes. Early coverage has been associated with higher union rates and lower complications and infection rates compared to those reconstructed after 5-7 days. Furthermore, early reconstruction improves flap survival and reduces surgical complexity, as microsurgical free flap procedures become more challenging with a delay due to an increased pro-thrombotic environment, tissue edema and the increasingly friable vessels. Only those patients presenting to facilities with an actual dedicated orthoplastic trauma service are likely to receive definitive treatment of a severe open fracture with tissue loss within the established parameters of good practice. We conclude that the surgeon's experience appears to be the decisive element in the orthoplastic approach, although reconstructive algorithms may assist in decisional and planification of surgery.
The concept of same-day discharge has garnered increasing significance within orthopedic surgery, particularly in hip and knee procedures. Despite initial concerns surrounding the absence of prolonged hospital care, a burgeoning body of evidence highlights numerous advantages associated with same-day discharge, ranging from mitigating in-hospital infections to offering substantial financial and psychosocial benefits for both patients and healthcare providers. In this study, we aim to scrutinize the trends in same-day discharge specifically within the realm of total hip arthroplasties. This retrospective analysis delves into the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database spanning from 2017 to 2021. Leveraging patient data sourced from the ACS NSQIP database, we sought to elucidate patterns and shifts in same-day discharge practices pertaining to total hip arthroplasties.Introduction
Method
Hip fractures, with a global age-standardised incidence rate (per 100,000 population) of 187.2 (2019), are a major public health problem. With a 7.71 billion population worldwide in 2019, hip fractures, in general, are affecting around 14.43 million people per year globally. We aim to provide a nationwide epidemiological analysis of trochanteric fractures and their respective surgical treatments. In this study we research the epidemiology of trochanteric and subtrochanteric fractures, as well as their most common kinds of osteosynthesis, on a nationwide scale in Germany. Data was retrieved from the national database of the German Ministry of Interior. ICD-10-GM and OPS-data from the period of 2006-2020 were analyzed, all patients with trochanteric/subtrochanteric fractures were included. Patients were grouped by age/gender and linear-regression was performed to calculate statistically significant correlations between variables/incidences.Introduction
Method
Fractures of the femoral neck occurring outside the capsule of the hip joint are assumed to have an intact blood supply and hence their conventional management is by fixation rather than arthroplasty. The dynamic hip screw and its variants have been used over many years to fix such fractures but have inherent vulnerabilities; they require an intact lateral femoral cortex, confer a relatively long moment arm to the redistribution of body weight and may cause a stress riser due to the plate with which they are fixed to the femur. Intramedullary devices for fixation of proximal femoral fractures have a shorter moment arm, can be distally locked with reduced perforation of the femoral cortex and are believed to be inherently more stable. For these reasons, a number of surgeons believe them to be superior to the DHS for all extracapsular fractures and their use is now widespread. In this study, we present the usage trends of both devices in extracapsular fractures over the last five years and set these results in the context of patient demographics. Our departmental electronic patient management system was used to identify all patients undergoing surgery coded as either DHS or its variants or intramedullary fixation of hip fracture. The patients’ age, sex and American Society of Anaesthesiologists grading were recorded. Comparison between groups was made using appropriate tests in SPSS.Background
Methods
Distal femoral fractures are 10 times less common than hip fractures. 12-month mortality has been reported as 25–30% but there is no longer-term data. In Northumbria hip fractures have a 5-year mortality of 68%. To analyse 5-year mortality in distal femur fractures in the Northumbrian NHS trust, and identify risk factors for mortality. To compare the results to literature standards and Northumbrian hip fracture data.Background
Objectives
The treatment of osteochondral lesions and osteoarthritis
remains an ongoing clinical challenge in orthopaedics. This review
examines the current research in the fields of cartilage regeneration,
osteochondral defect treatment, and biological joint resurfacing, and
reports on the results of clinical and pre-clinical studies. We
also report on novel treatment strategies and discuss their potential
promise or pitfalls. Current focus involves the use of a scaffold
providing mechanical support with the addition of chondrocytes or mesenchymal
stem cells (MSCs), or the use of cell homing to differentiate the
organism’s own endogenous cell sources into cartilage. This method
is usually performed with scaffolds that have been coated with a
chemotactic agent or with structures that support the sustained
release of growth factors or other chondroinductive agents. We also
discuss unique methods and designs for cell homing and scaffold
production, and improvements in biological joint resurfacing. There
have been a number of exciting new studies and techniques developed
that aim to repair or restore osteochondral lesions and to treat
larger defects or the entire articular surface. The concept of a
biological total joint replacement appears to have much potential. Cite this article:
With increasing emphasis on evidence-based medicine in healthcare, there is global increase in proportion of Level-1 and -2 articles in PUBMED. This study shows the trend of orthopaedic publications from different countries in comparison to other specialties. New medical knowledge is expected to improve health through change in existing practices. Articles need to convince readers of the validity of conclusions in order to bring about a change in practice. The last few decades have witnessed an increasing interest in critical appraisal of research aimed at assessing the ‘quality’ of evidence, a trend towards ‘Evidence Based Medicine’. Whether orthopaedic publications are also becoming more evidence-based has hitherto not been reported. This study aimed to compare the trend of publications originating from orthopaedic services versus other specialties, across different countries, with respect to major categories of levels of evidence.Summary Statement
Introduction
Ponseti first advocated his treatment for idiopathic clubfoot in the early 1950's. The method has only gained popularity and widespread use since the 1990's. Despite publications showing favourable results, there is little published data scrutinising the change in modes of talipes treatment. This study sought to define the trends in treatment for Idiopathic Clubfoot in Scotland over a twelve-year period (1997 – 2008). (i) A review was performed to identify the number of publications referencing the Ponseti method over the past 40 years. (ii) A structured questionnaire was sent to all Paediatric Orthopaedic practitioners in Scotland to ascertain the treatment methods used and over the time period. (iii) Data from the National Census for number of live births were combined with that obtained from the Scottish Morbidity Record (SMR01) for number of peritalar clubfoot surgeries performed over the study period. (iv) Similar data was also obtained for non-Talipes related peritalar surgeries, and data colleceted for the number of Tibialis Anterior transfer operations for this period. Clubfoot incidence data was measured indirectly by means of sample from the database of a tertiary referral Paediatric Orthopaedic Unit. Regression analysis was used to evaluate the trends over time. Review of the literature referencing the Ponseti method over the past 40 years showed an exponential increase from the late 1990's. The survey of Clubfoot management of Paediatric Orthopaedic Surgeons in Scotland showed a marked increase in use of the method over with this period. Over this period, the number of operations for clubfoot dropped substantially, from 55 releases in 1997 to 1 release in 2008. The linear equation estimated a decrease of approximately 5 surgical releases per year (R²= 0.87, p<0.05). In Scotland, most Tibialis Anterior transfers are performed at age 3years, the frequency of the procedure has increased in the latter half of the study period. In Scotland between 1997 and 2008, the number of peritalar (posterior, medial, posteromedial release) operations used in the primary treatment of idiopathic clubfoot has dropped substantially. This correlates with a marked increase in reference to the method within the literature and increased usage of the Ponseti technique by Paediatric Orthopaedic Consultants.
Metastatic osteosarcoma is seen in 10-20% of patients at initial presentation with the lung the most common site of metastasis. Historically, prognosis has been poor. We studied trends in survival in our small developed nation and aimed to identify correlations between the survival rate and three factors: newer chemotherapy, advances in radiological imaging and a more aggressive approach adopted by cardiothoracic surgeons for lung metastases. Our national bone tumour registry was used to identify patients at the age of 18 or under, who presented with metastatic disease at initial diagnosis between 1933 and 2006. There were 30 patients identified. Kaplan-Meier analysis was used to determine survival rates and univariate analysis was performed using the Cox regression proportional hazards model. Median survival has improved over the last 50 years; highlighted by the ‘Kotz’ eras demonstrating incremental improvement with more effective chemotherapy agents (p=0.004), and a current 5-year survival of 16%. Aggressive primary and metastatic surgery also show improving trends in survival. Three patients have survived beyond 5 years. The introduction of computerised tomography scanning has led to an increase in the prevalence of metastases at initial diagnosis. Metastatic osteosarcoma remains with a very poor prognostic factor, however, aggressive management has been shown to prolong survival.
Excessive opioid prescriptions after total joint arthroplasty (TJA) increase risks for adverse opioid related events, chronic opioid use, and increase the availability of opioids for unlawful diversion. Thus, decreasing postoperative prescriptions may improve quality after TJA. Concerns exist that a decrease in opioids prescribed may increase complications such as readmissions, emergency department (ED) visits or worsened patient reported outcomes (PROs). The purpose of this quality improvement study was to explore whether a reduction in opioids prescribed after TJA resulted in increased complications. Methods: Data originated from a statewide arthroplasty database (MARCQI). The database collects over 96% of all TJA performed in the state of Michigan, USA. Data was prospectively abstracted and included OMEs prescribed at discharge, readmissions, ED visits within 30 days and PROs. Data was collected one year before and after the creation of an opioid prescribing protocol that had decreased prescriptions by approximately 50% in opioid naive and tolerant patients.