Aims. Postoperative delirium (POD) and postoperative cognitive decline (POCD) are common surgical complications. In the UK, the Best Practice Tariff incentivizes the screening of delirium in patients with hip fracture. Further, a National Hip Fracture Database (NHFD) performance indicator is the reduction in the incidence of POD. To aid in its recognition, we sought to determine factors associated with POD and POCD in patients with hip fractures. Methods. We interrogated the NHFD data on patients presenting with hip fractures to our institution from 2016 to 2018. POD was determined using the 4AT score, as recommended by the NHFD and UK Department of Health. POCD was defined as a decline in Abbreviated Mental Test Score (AMTS) of two or greater. Using logistic regression, we adjusted for covariates to identify factors associated with POD and POCD. Results. Of the 1,224 patients presenting in the study period, 1,023 had complete datasets for final analysis. POD was observed in 242 patients (25%). On multivariate analysis only preoperative AMTS and American Society of Anesthesiologists grade (ASA) were independent predictors of POD. Every point increase in AMTS was associated with a fall in the odds of POD by a factor of 0.60 (95% confidence interval (CI) 0.56 to 0.63, p < 0.001). Every grade increase in ASA led to a 1.7-fold increase in the odds of POD (95% CI 1.13 to 2.50, p = 0.009). A preoperative AMTS of less than 8 was strongly predictive of POD with area under the receiver operating characteristic of 0.86 (95% CI 0.84 to 0.89). Only ASA was predictive of POCD—every grade increase in ASA led to a 2.6-fold increase in the odds of POCD (95% CI 1.7 to 4.0, p < 0.001). Conclusion. POD and POCD are common in the hip fracture patients. Preoperative AMTS and ASA are strong predictors of POD, and ASA predictive of POCD. This may aid in the earlier identification of those most at risk and suited for the patient consent and decision-making process. Cite this article: Bone Joint J 2020;102-B(12):1675–1681

Aims. Delirium is associated with adverse outcomes following hip fracture, but the prevalence and significance of delirium for the prognosis and ongoing rehabilitation needs of patients admitted from home is less well studied. Here, we analyzed relationships between delirium in patients admitted from home with 1) mortality; 2) total length of hospital stay; 3) need for post-acute inpatient rehabilitation; and 4) hospital readmission within 180 days. Methods. This observational study used routine clinical data in a consecutive sample of hip fracture patients aged ≥ 50 years admitted to a single large trauma centre during the COVID-19 pandemic between 1 March 2020 and 30 November 2021. Delirium was prospectively assessed as part of routine care by the 4 A’s Test (4AT), with most assessments performed in the emergency department. Associations were determined using logistic regression adjusted for age, sex, Scottish Index of Multiple Deprivation quintile, COVID-19 infection within 30 days, and American Society of Anesthesiologists grade. Results. A total of 1,821 patients were admitted, with 1,383 (mean age 79.5 years; 72.1% female) directly from home. Overall, 87 patients (4.8%) were excluded due to missing 4AT scores. Delirium prevalence in the whole cohort was 26.5% (460/1,734): 14.1% (189/1,340) in the subgroup of patients admitted from home, and 68.8% (271/394) in the remaining patients (comprising care home residents and inpatients when fracture occurred). In patients admitted from home, delirium was associated with a 20-day longer total length of stay (p < 0.001). In multivariable analyses, delirium was associated with higher mortality at 180 days (odds ratio (OR) 1.69 (95% confidence interval (CI) 1.13 to 2.54); p = 0.013), requirement for post-acute inpatient rehabilitation (OR 2.80 (95% CI 1.97 to 3.96); p < 0.001), and readmission to hospital within 180 days (OR 1.79 (95% CI 1.02 to 3.15); p = 0.041). Conclusion. Delirium affects one in seven patients with a hip fracture admitted directly from home, and is associated with adverse outcomes in these patients. Delirium assessment and effective management should be a mandatory part of standard hip fracture care. Cite this article: Bone Jt Open 2023;4(6):447–456

Hip fracture patients are vulnerable to delirium. This study examined the associations between delirium and outcomes including mortality, length of stay, post-discharge care requirements, and readmission. This cohort study collected validated healthcare data for all hip fracture patients aged ≥50 years that presented to a high-volume centre between March 2020-November 2021. Variables included: demographics, delirium status, COVID-19 status, treatment factors, and outcome measures. Wilcoxon rank sum or Chi-squared tests were used for baseline differences, Cox proportional hazard regression for mortality, logistic regression for post-discharge care requirements and readmission, and linear regression for length of stay. Analyses were adjusted for age, sex, deprivation, pre-fracture residence type and COVID-19. There were 1822 patients (mean age 81 years; 72% female) of which 496/1822 (27.2%) had delirium (4AT score ≥4). Of 371/1822 (20.4%) patients that died within 180 days of admission, 177/371 (47.7%) had delirium during the acute stay. Delirium was associated with an increased 30- and 180-day mortality risk (adjusted HR 1.74 (95%CI 1.15-2.64; p=0.009 and 1.74 (1.36-2.22; p<0.001), respectively), ten day longer total inpatient stay [adj. B.coef 9.80 (standard error 2.26); p<0.001] and three-fold greater odds of higher care requirements on discharge [Odds Ratio 3.07 (95% Confidence Interval 2.27-4.15; p<0.001)]. More than a quarter of patients had delirium during the hip fracture stay, and this was independently associated with increased mortality, longer length of stay, and higher post-discharge care requirements. These findings are relevant for prognostication and service planning, and emphasise the importance of effective delirium screening and evidence-based interventions in this vulnerable population

Perioperative delirium (POD) is not uncommon in orthopaedics. We prospectively followed one hundred and thirty-two arthroplasty patients and thirty hip fracture patients using POD as the outcome. Patient interviews, chart reviews and application of the Mini Mental Status Exam (MMSE) were used to identify risk factors for POD. Having two or more risk factors or low scores on the MMSE was predictive of POD. Development of POD significantly increased patient length of stay. It may be possible to identify “at risk” patients for POD and intervene preoperatively so as to improve outcomes. The purpose of this study was to identify risk factors for delirium in arthroplasty and hip fracture patients among routinely collected data. Risk factors for perioperative delirium (POD) in arthroplasty and hip fracture patients can be identified. In elderly hip fracture patients, cognitive impairment as measured by preoperative performance on the Mini Mental Status Exam (MMSE), appears to have a strong association with development of POD. As delirium is associated with adverse outcomes, it may be possible to target interventions to reduce the incidence of POD in patients who are at greatest risk, and potentially improve outcomes. The incidence of POD was lower in elective orthopaedic patients (13.6%) than in fracture patients (40%). Among elective arthroplasty patients, having two or more risk factors was associated with an eight-time increase in the incidence of delirium and increased length of stay (9.5 days versus six days). Length of stay was considerably higher in hip fracture patients with two or more risk factors (18.9 days vs. 9.9). A low score on the MMSE was the best predictor of developing POD in hip fracture patients. We recorded age, sensory impairment, functional status, history of previous POD, and use of alcohol or benzodiazepines, in one hundred and thirty-two hip or knee arthroplasty patients, and thirty elderly patients awaiting surgery for hip fracture. All patients completed the MMSE preoperatively. Delirium was documented prospectively by the Confusion Assessment Method. POD has an adverse effect on outcomes and is not uncommon in orthopaedics. Risk factors have been identified that could be used for preoperative screening and intervention

Aims. The aims of this study were to evaluate the incidence of reoperation (all cause and specifically for periprosthetic femoral fracture (PFF)) and mortality, and associated risk factors, following a hemiarthroplasty incorporating a cemented collarless polished taper slip stem (PTS) for management of an intracapsular hip fracture. Methods. This retrospective study included hip fracture patients aged 50 years and older treated with Exeter (PTS) bipolar hemiarthroplasty between 2019 and 2022. Patient demographics, place of domicile, fracture type, delirium status, American Society of Anesthesiologists (ASA) grade, length of stay, and mortality were collected. Reoperation and mortality were recorded up to a median follow-up of 29.5 months (interquartile range 12 to 51.4). Cox regression was performed to evaluate independent risk factors associated with reoperation and mortality. Results. The cohort consisted of 1,619 patients with a mean age of 82.2 years (50 to 104), of whom 1,100 (67.9%) were female. In total, 29 patients (1.8%) underwent a reoperation; 12 patients (0.7%) sustained a PFF during the observation period (United Classification System (UCS)-A n = 2; UCS-B n = 5; UCS-C n = 5), of whom ten underwent surgical management. Perioperative delirium was independently associated with the occurrence of PFF (hazard ratio (HR) 5.92; p = 0.013) and surgery for UCS-B PFF (HR 21.7; p = 0.022). Neither all-cause reoperation nor PFF-related surgery was independently associated with mortality (HR 0.66; p = 0.217 and HR 0.38; p = 0.170, respectively). Perioperative delirium, male sex, older age, higher ASA grade, and pre-fracture residential status were independently associated with increased mortality risk following hemiarthroplasty (p < 0.001). Conclusion. The cumulative incidence of PFF at four years was 1.1% in elderly patients following cemented PTS hemiarthroplasty for a hip fracture. Perioperative delirium was independently associated with a PFF. However, reoperation for PPF was not independently associated with patient mortality after adjusting for patient-specific factors. Cite this article: Bone Jt Open 2024;5(4):269–276

Purpose: It is known that postoperative delirium and hypoxia are factors that make mobilisation of elderly patients more difficult. Our purpose was to estimate the rate of hypoxia and delirium postoperatively, and their possible correlation, in elderly people suffering from a hip fracture. Material: One hundred-seventeen patients (35 male, 82 female) over 65 years old were studied. Sixty two of them, who had a fracture of the neck of the femur and 15 with an intertrochanteric fracture were treated with a hemiarthroplasty, and 40 who sustained an intertrochanteric fracture were treated with internal fixation with a gliding screw and a plate. Spinal anaesthesia was used in all patients. Their age was 65–97 (average 79, 7). Patients suffering from dementia or Alzheimer were excluded. Method: We counted satO2 preoperatively and until the fourth postoperative day. Postoperative delirium was assessed with the Confusion Assessment Method (CAM). Postoperatively, O2 was given at patients with satO2< 90 or when saturation was 5% lower than the preoperative. Results: Hypoxia occurred in 60 patients (51,28%), which was usually reduced until the 4th pop day. In two patients who suffered from chronic respiratory failure, hypoxia persisted until the 10th pop day. Postoperative delirium occurred in 31 patients (26,5%). Seventeen of then had also hypoxia. Two patients didn’t recover until their discharge from the hospital. In one of them the delirium persists 3 months pop. Correlation between delirium and hypoxia was not noticed (p< 0,0024), neither the delirium was better after the administration of O2 in hypoxaemic patients, altought satO2 was made better. Conclusion: Hypoxia, postoperatively, in elderly patients, sufering from hip fracture is usual, but it is made better after the 4th pop day. Postoperative delirium in these patients is also usual. In our study there was no correlation between delirium and hypoxia. Delirium wasn’t any better after administration of O2

Aims. This study aimed to determine whether lateral femoral wall thickness (LWT) < 20.5 mm was associated with increased revision risk of intertrochanteric fracture (ITF) of the hip following sliding hip screw (SHS) fixation when the medial calcar was intact. Additionally, the study assessed the association between LWT and patient mortality. Methods. This retrospective study included ITF patients aged 50 years and over treated with SHS fixation between 2019 and 2021 at a major trauma centre. Demographic information, fracture type, delirium status, American Society of Anesthesiologists grade, and length of stay were collected. LWT and tip apex distance were measured. Revision surgery and mortality were recorded at a mean follow-up of 19.5 months (1.6 to 48). Cox regression was performed to evaluate independent risk factors associated with revision surgery and mortality. Results. The cohort consisted of 890 patients with a mean age of 82 years (SD 10.2). Mean LWT was 27.0 mm (SD 8.6), and there were 213 patients (23.9%) with LWT < 20.5 mm. Overall, 20 patients (2.2%) underwent a revision surgery following SHS fixation. Adjusting for covariates, LWT < 20.5 mm was not independently associated with an increased revision or mortality risk. However, factors that were significantly more prevalent in LWT < 20.5 mm group, which included residence in care home (hazard ratio (HR) 1.84; p < 0.001) or hospital (HR 1.65; p = 0.005), and delirium (HR 1.32; p = 0.026), were independently associated with an increased mortality risk. The only independent factor associated with increased risk of revision was older age (HR 1.07; p = 0.030). Conclusion. LWT was not associated with risk of revision surgery in patients with an ITF fixed with a SHS when the calcar was intact, after adjusting for the independent effect of age. Although LWT < 20.5 mm was not an independent risk factor for mortality, patients with LWT < 20.5 mm were more likely to be from care home or hospital and have delirium on admission, which were associated with a higher mortality rate. Cite this article: Bone Jt Open 2024;5(2):123–131

(Case) 79-year-old woman. Past history, in 1989, right femur valgus osteotomy. in 1991, THA at left side. Follow-up thereafter. Hyaluronic acid injection for both knee osteoarthritis. (Clinical course)Her right hip pain getting worse and crawling indoors from the beginning of July 2013. We did right hybrid THA at August 2013(posterior approach, TridentHA cup, Exeter stem, Biolox Forte femoral head 28mm). But immediately, she dislocated twice than the third day after surgery because she became a delirium. It has been left by nurse for about 6 hours because of the midnight after the second dislocation. Next morning, check the dislocation limb position, closed reduction wasdone under intravenous anesthesia. As a result of waking up from the anesthesia, and complained of paralysis and violent pain in the right leg backward. A right lower extremity nerve findings, there is pain in the lower leg after surface about the calf, there was no apparent perception analgesia. Toe movement is weak, but the G-toe planter anddorsiflexion possible about M2, and neurological symptoms to relieved by flexion(above 70 degrees) of the right hip joint. Therefore, we thought that she suffered anterior dislocation of the sciatic nerve by the stem neck (retraction), judged to closed reduction was impossible, open reduction surgery was performed after waitingat hip flex position. But paralysis is gradually worsened during waiting surgery, toes movement had become impossible to operating room admission. Sciatic nerve is caught in front of the stem neck as expected, operative findings were able to finally reduction after removing the femoral head after dislocation. Anteversion of the cup was changed to 25 degrees from 15 degrees, and changed to 32mm diameter metal head and polyethylene liner. And we needed Intensive Care Unit(ICU) management after surgery for prevent recurrence of dislocation. Fitted with a hip brace for her, has not been re-dislocation. The sciatic nerve palsy improved in three months after the operation, the patient became able to walk without a cane. (Summary) We experienced a rare case suffered anterior dislocation of the sciatic nerve by the stem neck, and she had a good result after open reduction surgery

Aims

National hip fracture registries audit similar aspects of care but there is variation in the actual data collected; these differences restrict international comparison, benchmarking, and research. The Fragility Fracture Network (FFN) published a revised minimum common dataset (MCD) in 2022 to improve consistency and interoperability. Our aim was to assess compatibility of existing registries with the MCD.

Aims. The aims of this study were to evaluate the incidence of postoperatively restricted weight-bearing and its association with outcome in patients who undergo surgery for a fracture of the hip. Patients and Methods. Patient aged > 60 years undergoing surgery for a hip fracture were identified in the 2016 National Surgical Quality Improvement Program (NSQIP) Hip Fracture Targeted Procedure Dataset. Analysis of the effect of restricted weight-bearing on adverse events, delirium, infection, transfusion, length of stay, return to the operating theatre, readmission and mortality within 30 days postoperatively were assessed. Multivariate regression analysis was used to adjust for confounding demographic, comorbid and procedural characteristics. Results. Of the 4918 patients who met inclusion criteria, 3668 (63.53%) were allowed to weight-bear as tolerated postoperatively. Controlling for patient and procedural factors, multivariate odds of any adverse event, major adverse event, delirium, infection, transfusion, length of stay ≥ 75th percentile (six days) and mortality within 30 days were all higher in patients with weight-bearing restrictions. Notably, there were no differences for thromboembolic events, return to the operating theatre or readmission within 30 days between the groups. Conclusion. Elderly patients with a fracture of the hip with postoperative weight-bearing restrictions have a significantly greater risk of developing most adverse events compared with those who are encouraged to weight-bear as tolerated. These findings emphasize the importance of immediate weight-bearing as tolerated to optimize the outcome in these frail patients; however nearly 25% of surgeons fail to meet this evidence-based guideline. Cite this article: Bone Joint J 2018;100-B:1377–84

The growth of life expectancy during the last decades has led to an increment in age-related conditions such as hip arthritis and fractures. On the other hand, these elderly patients will present a higher incidence of mental diseases which, in some studies, have been associated with inferior results. This study aims to evaluate the differences in early complication rates between patients with cognitive impairment compared with those without this condition following total hip replacement for osteoarthritis or fracture in the context of contemporary perioperative care protocols. We conducted a retrospective cohort study where cognitively-impaired patients who required primary hip arthroplasty were compared to a propensity-score matched cohort of patients without cognitive alterations. Early major complications were measured and analyzed in order to determine significant differences. Screening and matching. 1196 patients were identified during the study period. After screening for inclusion and exclusion criteria and matching, two cohorts comprising 65 patients each were compared. After performing the propensity-score match, no significant differences were found in covariates between the two groups. Outcomes. The occurrence of delirium was more frequent in patients with cognitive deficit (27.5%) than in the control group (9%), p<0.001. No significant differences were found among groups regarding myocardial infarction, venous thromboembolism, blood transfusion requirement, 30-day readmission, in-hospital death, 90-days death, dislocation or surgical site infection. The composite outcome of any adverse event did not exhibit a significant difference either. To our knowledge, this is the first study which demonstrates similar outcomes between patients with cognitive impairment and those without these alterations. Our results might indicate that contemporary protocols and implants are bridging the traditional gap between these two populations. These findings support the use of total hip arthroplasty in patients with mental alterations when indicated, especially in those institutions with strict perioperative protocols

Aims. While interdisciplinary protocols and expedited surgical treatment improve the management of hip fractures in the elderly, the impact of such interventions on patients specifically undergoing arthroplasty for a femoral neck fracture is not clear. We sought to evaluate the efficacy of an interdisciplinary protocol for the management of patients with a femoral neck fracture who are treated with an arthroplasty. Methods. In 2017, our institution introduced a standardized interdisciplinary hip fracture protocol. We retrospectively reviewed adult patients who underwent hemiarthroplasty (HA) or total hip arthroplasty (THA) for femoral neck fracture between July 2012 and March 2020, and compared patient characteristics and outcomes between those treated before and after the introduction of the protocol. Results. A total of 157 patients were treated before the introduction of the protocol (35 (22.3%) with a THA), and 114 patients were treated after its introduction (37 (32.5%) with a THA). The demographic details and medical comorbidities were similar in the two groups. Patients treated after the introduction of the protocol had a significantly reduced median time between admission and surgery (22.8 hours (interquartile range (IQR) 18.8 to 27.7) compared with 24.8 hours (IQR 18.4 to 43.3) (p = 0.042), and a trend towards a reduced mean time to surgery (24.1 hours (SD 10.7) compared with 46.5 hours (SD 165.0); p = 0.150), indicating reduction in outliers. Patients treated after the introduction of the protocol had a significantly decreased rate of major complications (4.4% vs 17.2%; p = 0.005), decreased median hospital length of stay in hospital (4.0 days vs 4.8 days; p = 0.008), increased rate of discharge home (26.3% vs 14.7%; p = 0.030), and decreased one-year mortality (14.7% vs 26.3%; p = 0.049). The 90-day readmission rate (18.2% vs 21.7%; p = 0.528) and 30-day mortality (3.7% vs 5.1%; p = 0.767) did not significantly differ. Patients who underwent HA were significantly older than those who underwent THA (82.1 years (SD 10.4) vs 71.1 years (SD 9.5); p < 0.001), more medically complex (mean Charlson Comorbidity Index 6.4 (SD 2.6) vs 4.1 (SD 2.2); p < 0.001), and more likely to develop delirium (8.5% vs 0%; p = 0.024). Conclusion. The introduction of an interdisciplinary protocol for the management of elderly patients with a femoral neck fracture was associated with reduced time to surgery, length of stay, complications, and one-year mortality. Such interventions are critical in improving outcomes and reducing costs for an ageing population. Cite this article: Bone Joint J 2021;103-B(7 Supple B):3–8

Abstract. Background. Elderly patients with degenerative lumbar disease are increasingly undergoing posterior lumbar decompression without instrumented stabilisation. There is a paucity of studies examining clinical outcomes, morbidity & mortality associated with this procedure in this population. Methods. A retrospective analysis of aged 80–100 years who underwent posterior lumbar decompression without instrumented stabilisation at University Hospitals of Derby &Burton between 2016–2020. Results. Total 167 eligible patients, 163 octogenarians & 4 nonagenarians. Mean age was 82.78 ± 3.07 years. Mean length of hospital stay 4.79 ± 10.92 days. 76% were pain free at 3months following decompression. The average Charleston co-morbidity index (CCI) was 4.87. No association found with CCI in predicting mortality (ODD ratio 0.916, CI95%). 17patients suffered complications; dural tear (0.017%), post-op paralysis (0.017%), SSI(0.01%), and 0.001% of hospital acquired pneumonia, delirium, TIA, urinary retention, ileus, anaemia. High BMI (35+) was associated with increased incidence of complication (CI 95%, p<0.002). There was significant social drift following discharge as 147 patients went home and 4 patients to rehabilitation facility (p<0.001FE test). The mean operative time was 91.408±41.17 mins and mean anaesthetic time was 36.8±16.06 mins. Prolonged operative time was not associated with increased mortality.2year revision decompression rate was 0.011%. Conclusion. Posterior lumbar decompression without instrumented stablisation in elderly is safe & associated with low mortality with 99.5%survival at 1 year. It significantly improves PROMs & has extremely low revision rate. Incidence of post-op complication is <0.05% and 54% of patients get discharged within 72hours of surgery. Careful selection & optimising patients with high BMI would reduced perioperative morbidity and mortality

For some years, there has been vast international interest in creating models for joint efforts between geriatricians and orthopedic surgeons. We present data from two such models. For the first time in Denmark, the Department of Orthopedics Bispebjerg University Hospital (BUP) recruited two full-time geriatricians in September 2009. They were assigned an independent unit meant for severely ill orthopaedic patients with high comorbidity and polypharmacy. These two geriatricians had, during the previous two years, consulted another orthopaedic department at Gentofte University Hospital (GUH) in a neighbouring community three times a week. The aim of their intervention was then to optimize treatment for comorbidity, to clarify indication of acute fall-assessment, osteoporosis diagnosis and treatment, presence of delirium and dementia. Methods. A total of 1344 hip fracture patients (age 70 years) divided into three populations were included in this study. Mortality data were collected from the Danish Civil Registry. Population 1 (P1), n = 645 was included at GUH from January 1, 2006 to December 31, 2007. During the entire period, the patients had access to a senior consultant in geriatric medicine three times a week. In this population, the majority of patients were assessed for dementia (n = 636), delirium (n = 627) and Barthel Index (Barthel100) at admission (n = 394). Population 2 (P2), n = 381 included at BUH from September 1, 2009 until July 8, 2010 with orthogeriatric access. Population 3 (P3), n = 318 were included at BUH from September 28, 2008 until August 31, 2009 with no orthogeriatric access. Age mean (SD): P1 84.7 (6.8), P2 85.5 (7.3), P3 85.3 (14.3) P = 0.1(ANOVA) Sex ratio: females/males: P1 0.73/0.27, P2 0.80/0.20, P3 0.75/0.25 P = 0.09 Chi square). Results. In-hospital mortality rate: P1 4.8%, P2 6.3%, P3 9.1% P = 0.03 (Chi square). Three month mortality: In P1 dementia, delirium and Barthel Index (below 50 versus above 50) were all strong predictors: No dementia: 53/383 (13.8%) versus dementia present 68/253 (26.9%) died, P = 0001 (log-rank test). No delirium 69/456 (15.1%) versus delirium present 47/171 (27.5%) died F = 0.0004 (log-rank test) Barthel Index 50 38/372 (10.2%) versus Barthel<50 7/22 (31.8%) died P = 0.0004. Conclusion. This paper reports data from two different models with orthogeriatric service. Our data present delirium, dementia and Barthel Index to be very strong predictors for three month mortality (P1). Despite the time needed to implement a new orthogeriatric unit and the fact that the geriatricians only assessed a proportion of hip fracture patients, in-hospital mortality was reduced significantly for the total hip-fracture population (P2) within the first 10 months

Background. As life expectancy increases, the number of octogenarians requiring primary and revision total knee arthroplasty (TKA) is increasing. Recently, primary TKA has become a common treatment option in octogenarians. However, surgeons are still hesitant about performing revision TKA on octogenarians because of concerning about risk- and cost-benefit. The purpose of this study was to investigate postoperative complications and mid-term survival in octogenarians following primary and revision total knee arthroplasty (TKA). Methods. We retrospectively reviewed 231 primary TKAs and 41 revision TKAs performed on octogenarians between 2000 and 2016. The mean age was 81.9 for primary TKA and 82.3 for revision TKA (p=0.310). The American Society of Anesthesiologists (ASA) score was not different, but the age-adjusted Charlson comorbidity index was higher in revision TKA (4.4 vs. 4.8, p=0.003). The mean follow-up period did not differ (3.8 vs. 3.5 years, p=0.451). The WOMAC scores and range of motion (ROM) were evaluated. The incidence of postoperative complication and survival rate (end point; death determined by telephone or mail communication with patient or family) were investigated. Results. The postoperative WOMAC and ROM were better in primary TKA (33.1 vs. 47.2, p<0.001; 128.9° vs. 113.6°, p<0.001). The most common postoperative complication was delirium in both groups (7.4% vs. 14.6%, p=0.131). There were no differences in the specific complication rates between the two groups. The 5- and 10-year survival rates were 87.2% and 62.9%, respectively, in primary TKA and 82.1% and 42.2%, respectively, in revision TKA (p=0.017). Conclusions. Both primary and revision TKAs are viable options for octogenarians when considering the clinical results and mid-term survival. Delirium needs to be managed appropriately as the most common complication in both primary and revision TKAs for octogenarians

Introduction. Total knee arthroplasty (TKA) is an effective surgical intervention, which alleviates pain and improves function and health-related quality of life in patients with end-stage arthritis of the knee joint. With improvements in anesthesia, general health care, and surgical techniques, this procedure has become widely accepted for use in very elderly patients. However, many elderly patients tend to have compromised function and low reserve capabilities of organs and are therefore likely to develop various complications during the perioperative period. Thus, elderly patients often hesitate to undergo simultaneous bilateral TKA (SBTKA). Our purpose was to report the short-term results and clinical complications of octogenarians undergoing SBTKA. Materials and Methods. Between 2015 and 2016 all patients greater than 80years of age who underwent SBTKA by a single surgeon were retrospectively evaluated demographics, comorbidity, complications, and 30days mortality following SBTKA. Arthroplasty was performed sequentially under general anesthesia by one team led by primary surgeon. After the first knee, the patient's cardiopulmonary status was assessed by anesthesiology to determine whether or not to begin the second side. Cardiopulmonary decompensation, such as significant shifts in heart rate, oxygen saturation or blood pressure, was not showed. Then the second procedure was undertaken. Inclusion criteria of this study was underlying diseases were osteoarthritis. Exclusion criteria were (1) previous knee surgery; (2) underlying diseases were osteonecrosis, rheumatoid arthritis, fracture, and others. Fifty-seven patients with an average age of 82.7years were identified. The results of these procedures were retrospectively compared with those of patients greater than 80years of age of 89 patients unilateral TKA (UTKA) that had been performed by the same surgeon. Results. The study groups did not differ significantly with regard to age, gender, or body mass index. The mean age was 82.7years with a mean body mass index of 25.8 for the SBTKA group, compared with 84.0years with a mean body mass index of 24.9 for the UBTKA group. The length of hospital stay was longer in SBTKA groups. There was no serious complication. No deaths, no pulmonary embolisms and no nerve paralysis occurred within 30days in both groups. There was one wound problem in SBTKA group, compared 10 wound problem in UBTKA group; this difference was significant. Three deliriums occurred in SBTKA group, compared 13 deliriums in UBTKA group; this difference was significant. Minor complications included urinary tract infection, decubitus ulcer, transfusion reaction and ileus were noted seven in SBTKA group, compared in 11 UBTKA group; this difference was not significant. Conclusions. Complications and mortality are not higher for SBTKA compared to UTKA, SBTKA can be a safe and effective option for octogenarians

The October 2015 Trauma Roundup. 360 . looks at: PCA not the best in resuscitation; Impact of trauma centre care; Quality of life after a hip fracture; Recovery and severity of injury: open tibial fractures in the spotlight; Assessment of the triplane fractures; Signs of an unstable paediatric pelvis; Safe insertion of SI screws: are two views required?; Post-operative delirium under the spotlight; Psychological effects of fractures; K-wires cost effective in DRAFFT

Introduction. Despite recent national advances in the care for the hip fracture patient, significant morbidity and mortality persists. Some of this morbidity is attributable to the analgesia provided in the hospital setting. The National Institute of Clinical Excellence recommends the use of simple oral analgesia including opioids, with fascia-iliac blocks used as an adjunct. Literature review reveals a paucity of evidence on this topic. The aim of this study was to evaluate the efficacy of fascia iliac blocks through analysis of pre and post-operative opioid usage, post-operative delirium, time to bowel opening and naloxone use. Methods. A retrospective study was performed between September-December 2013. Inclusion criteria were determined. 41 patients who received spinal anaesthesia alone and 41 patients who received spinal anaesthesia and a fascia-iliac block were included. Results. Patients who received a fascia-iliac block received significantly less post-operative and total analgesia (p=0.04, p=0.03), had lower rates of delirium (p=0.03) and those patients which were discharged directly home had a shorter inpatient stay (p=0.03). No patients who received a fascia-iliac block needed naloxone to reverse opioid toxicity, whilst two non fascia iliac block patients did. Conclusions. Fascia iliac blocks either given in A&E or at the time of spinal anaesthesia are a useful adjunct to provide analgesia in the hip fracture patient. The John Radcliffe hospital aims to incorporate fascia-iliac blocks into the care pathway for the hip fracture patient

Aims. Depression can significantly affect quality of life and is associated with higher rates of medical comorbidities and increased mortality following surgery. Although depression has been linked to poorer outcomes following orthopaedic trauma, total joint arthroplasty and spinal surgery, we wished to examine the impact of depression in elective total shoulder arthroplasty (TSA) as this has not been previously explored. . Patients and Methods. The United States Nationwide Inpatient Sample (NIS) was used to identify patients undergoing elective TSA over a ten-year period. Between 2002 and 2012, 224 060 patients underwent elective TSA. Results. Among the identified patients who had undergone TSA, 12.4% had a diagnosis of a history of depression. A diagnosis of depression was twice as common in women compared with men (16.0% vs 8.0%, p < 0.001), and more frequent in those with low income and Medicaid insurance (p < 0.001). A diagnosis of depression was an independent risk factor for post-operative delirium (odds ratio (OR) 2.29, p < 0.001), anaemia (OR 1.65, p < 0.001), infection (2.09, p = 0.045) and hospital discharge to a placement other than home (OR 1.52, p < 0.001) . Conclusion. A history of clinical depression is present in 12.4% of patients undergoing elective TSA and the disease burden is projected to increase further in the future. Depression is often underdiagnosed and pre-operative screening and appropriate peri-operative management of patients is encouraged. Take home message: The awareness that clinical depression is associated with increased complications following total shoulder arthroplasty provides physicians an opportunity for early intervention in this at-risk population. Cite this article: Bone Joint J 2016;98-B:818–24