Aim. The treatment of fracture-related infections (FRI) focuses on obtaining fracture healing and eradicating infection to prevent osteomyelitis. Treatment guidelines include removal, exchange, or retention of the implants used according to the stability of the fracture and the time from the infection. Infection of a fracture in the process of healing with a stable fixation may be treated with implant retention, debridement, and antibiotics. Nonetheless, the retention of an intramedullary nail is a potential risk factor for failure, and it is recommended to exchange or remove the nail. This surgical approach implies additional life-threatening risks in elderly fragile hip fracture patients. Our study aimed to analyze the results of implant retention for the treatment of infected nails in elderly hip fracture patients. Methods. Our retrospective analysis included patients 65 years of age or older with an acute fracture-related infection treated with implant retention from 2012 to 2020 in 6 Spanish hospitals with a minimum 1-year follow-up. Patients that required open reduction during the initial fracture surgery were excluded. Variables included in our analysis were patient demographics, type of fracture, date of FRI diagnosis, causative microorganism, and outcome. Treatment success was defined as fracture healing with infection eradication without the need for further hospitalization. Results. A total of 48 patients were identified. Eight patients with open reduction were excluded and 11 did not complete a 1-year follow-up. Out of the 29 remaining patients, the mean age was 81.5 years, with a 21:9, female to male ratio. FRI was diagnosed between 10 and 48 days after initial surgery (mean 26 days). Treatment success was achieved in 24 patients (82.7%). Failure was objectivated in polymicrobial infections or infections caused by microorganisms resistant to antibiofilm antibiotics. Seven patients required more than one debridement with a success rate of 57%. Twelve patients had an infection diagnosed after 21 days from the initial surgery and implant retention was successful in all of them. Conclusion. Our results suggest implant retention is a valid therapeutic approach for fracture-related infection in elderly hip fracture patients treated by closed reduction and intramedullary nailing

Purpose. The objective of this meta-analysis was to compare the effects of early and delayed surgery on the risk of mortality, common post-operative complications, and length of hospital stay among elderly hip fracture patients. Methods. We searched MEDLINE and EMBASE for relevant prospective studies evaluating surgical delay in patients undergoing surgery for hip fractures published in all languages between 1966 and 2008. Two reviewers independently assessed methodological quality and extracted relevant data. Results. Of 1939 citations identified, 16 observational studies that included a total of 13,478 patients with complete mortality data (1764 total deaths) met our inclusion criteria. Irrespective of the cut-off for delay (24, 48, or 72 hours), earlier surgery (< 24, < 48, or < 72 hours) was significantly associated with a reduction in the risk of unadjusted one-year mortality (relative risk 0.55; 95% confidence interval, 0.40 to 0.75, p=0.0002) and adjusted mortality rates (relative risk 0.81; 95% confidence interval, 0.68 to 0.96, p=0.01). Based on unadjusted data, earlier surgery also reduced in-hospital pneumonia (relative risk 0.59; 95% confidence interval, 0.37 to 0.93, p=0.02), pressure sores (relative risk 0.48; 95% confidence interval, 0.34 to 0.69, p< 0.0001) and hospital stay (weighted mean difference 9.95 days; 95% confidence interval, 1.52 to 18.39, p=0.02). Conclusion. Earlier surgery was associated with a reduced risk of mortality, post-operative pneumonia, pressure sores, and length of hospital stay among elderly hip fracture patients. This suggests that it may be warranted to reduce surgical delays whenever possible. However, unadjusted analyses are certainly confounded, and residual confounding may be responsible for apparent effects in adjusted analyses. A definitive answer to this issue will require the conduct of a large randomised controlled trial to evaluate the effect of earlier surgery among patients admitted with a hip fracture

A clinical evaluation of the effect of MRI scan to bring about a change in surgical management of elderly patients who present with hip fracture with no history of trauma or a suspicious looking lesion on x-rays. Many of these patients present with or without history of previous malignancy or bone disorder.

We evaluated that if the delay in treatment within 36 hours as per national guide lines is justified to benefit patients.

Current recommendations advocate for surgery within 48 hours from time of injury as a keystone in care for elderly patients with hip fractures. A spare population density within regional Australia provides physical challenges to meet time critical care parameters. This study aims to review the impact of delays to timely surgery for elderly hip fracture patients within a regional Australian population. A retrospective, comparative analysis was undertaken of 140 consecutive hip fracture patients managed at a single rural referral hospital, from June 2020 until June 2021. Factors such as age, time to transfer, time to surgery, 30-day complication and 6-month complication rates were collected. Statistical analysis was performed where applicable. Mean time to surgery was 33.9 hours. A greater proportion of patients whom directly presented underwent surgery within the recommended 48 hours (91.5% vs 75.3%). The statistically significant delay in time to surgery was found to be 6.4 hours. Lower 180-day morbidity and mortality rates were observed in patients undergoing surgery within 48 hours (13.8% vs 36%), This is in comparison to the overall mortality rate of 19.2%. Delay to surgery for elderly hip fracture patients was associated with an increase 30-day and 180-day morbidity and mortality rate. A greater proportion of patients transferred from peripheral hospitals experienced a delay in surgery. Early transfer and prioritization of such patients is recommended to achieve comparative outcomes for rural and remote Australians

Fracture of the acetabulum can result in damage to the articular surface that ranges from minimal to catastrophic. Hip arthroplasty may be required for more severe injuries due to marked articular surface damage, post traumatic degenerative changes, persistent malunion or nonunion, or occasionally avascular necrosis and destruction of the femoral head. These problems may be seen following both closed and open fracture treatment, but prior open reduction and internal fixation often makes subsequent THA more difficult due to soft tissue scarring and retained hardware. In select acute acetabular fracture cases with severe initial comminution of the joint, open reduction and fixation can be technically impossible or so clearly destined to early failure that initial fracture treatment with combined limited fixation and simultaneous THA is the best option, especially in osteoporotic elderly fracture patients. Problems which may be encountered during any THA in a patient with a prior acetabular fracture include: difficult exposure due to soft tissue defects and scarring, presence of heterotopic ossification, and nerve palsy from the original fracture or subsequent osteosynthesis. Retained hardware can present significant challenges and frequently is left in place or removed in part or completely, when intraarticular in location or blocking preparation of the acetabular cavity and placement of the cup. Additional potential problems include residual deformity and malunion, persistent pelvic dissociation or nonunion of fracture fragments, cavitary or segmental bone loss from displaced or resorbed bone fragments, and occasionally occult deep infection. Preoperative assessment and planning should include careful consideration of the most appropriate surgical approach, which may be impacted by the need for hardware removal. Screening laboratory studies and aspiration of the hip may prove helpful in excluding associated deep infection. Intraoperative sciatic nerve monitoring may be of assistance in patients with partial residual nerve deficits or where extensive posterior exposure and mobilization of the sciatic nerve is needed for hardware removal or excision of heterotopic ossification. Metal cutting tools to allow partial removal of long plates and adjunctive equipment for removal of broken or stripped screws should be routinely available during these cases. Careful preoperative planning regarding implant and reconstructive options can also ensure availability of proper components and equipment. Often implants and techniques developed for revision surgery for management of major bone deficiencies are needed. Reported results suggest that surgery is frequently prolonged, can be associated with greater blood loss and may result in increased risk of post-arthroplasty heterotopic ossification when compared to routine primary procedures. Bone stock and fracture union may be better in patients with prior internal fixation than in those with nonoperative treatment of major displaced acetabular fractures. Available long-term results document more durable results with lower rates of aseptic loosening with uncemented acetabular fixation compared to cemented acetabular components. These patients are at higher risk of revision and failure than patients undergoing THA for simple osteoarthritis, though initial short-term results are comparable to conventional hip arthroplasty patients, as long as early wound healing problems and deep infection can be avoided, which is a greater risk for acute THA for initial fracture care. The application of newer implant designs, highly porous ingrowth materials, and methods for management of acetabular bone deficiency developed for revision THA have helped improve results in this challenging subset of primary THA patients

Periprosthetic fractures around the femur during and after total hip arthroplasty (THA) remain a common mode of failure. It is important therefore to recognise those factors that place patients at increased risk for development of this complication. Prevention of this complication, always trumps treatment. Risk factors can be stratified into: 1. Patient related factors; 2. Host bone and anatomical considerations; 3. Procedural related factors; and 4. Implant related factors. Patient Factors. There are several patient related factors that place patients at risk for development of a periprosthetic fracture during and after total hip arthroplasty. Metabolic bone disease, particularly osteoporosis increases the risk of periprosthetic fracture. In addition, patients that smoke, have long term steroid use or disuse, osteopenia due to inactivity should be identified. A metabolic bone work up and evaluation of bone mineralization with a bone densitometry test can be helpful in identifying and implementing treatment prior to THA. Pre-operative Host Bone and Anatomic Considerations. In addition to metabolic bone disease the “shape of the bone” should be taken into consideration as well. Dorr has described three different types of bone morphology (Dorr A, B, C), each with unique characteristics of size and shape. It is important to recognise that not one single cementless implant may fit all bone types. The importance of templating a THA prior to surgery cannot be overstated. Stem morphology must be appropriately matched to patient anatomy. Today, several types of cementless stem designs exist with differing shape and areas of fixation. It is important to understand via pre-operative templating which stem works best in what situation. Procedural Related Factors. There has been a resurgence in interest in the varying surgical approaches to THA. While the validity and benefits of each surgical approach remains a point of debate, each approach carries with it its own set of risks. Several studies have demonstrated increased risk of periprosthetic fractures during THA with the use of the direct anterior approach. Risk factors for increased risk of periprosthetic fracture may include obesity, bone quality and stem design. Implant Related Factors. As mentioned there are several varying cementless implant shapes and sizes that can be utilised. There is no question that cementless fixation remains the most common mode of fixation in THA. However, one must not forget the role of cemented fixation in THA. Published results on long term fixation with cemented stems are comparable if not exceeding those of press fit fixation. In addition, the literature is clear that cemented fixation in the elderly hip fracture patient population is associated with a lower risk of periprosthetic fracture and lower risk of revision. The indication and principles of cemented stem fixation in THA should not be forgotten

Aims. COVID-19 remains the major focus of healthcare provision. Managing orthopaedic emergencies effectively, while at the same time protecting patients and staff, remains a challenge. We explore how the UK lockdown affected the rate, distribution, and type of orthopaedic emergency department (ED) presentations, using the same period in 2019 as reference. This article discusses considerations for the ED and trauma wards to help to maintain the safety of patients and healthcare providers with an emphasis on more remote geography. Methods. The study was conducted from 23 March 2020 to 5 May 2020 during the full lockdown period (2020 group) and compared to the same time frame in 2019 (2019 group). Included are all patients who attended the ED at Raigmore Hospital during this period from both the local area and tertiary referral from throughout the UK Highlands. Data was collected and analyzed through the ED Information System (EDIS) as well as ward and theatre records. Results. A total of 1,978 patients presented to the ED during the lockdown period, compared to 4,777 patients in the same timeframe in 2019; a reduction of 58.6%. Orthopaedic presentations in 2020 and 2019 were 736 (37.2%) and 1,729 (36.2%) respectively, representing a 57.4% reduction. During the lockdown, 43.6% of operations were major procedures (n = 48) and 56.4% were minor procedures (n = 62), representing a significant proportional shift. Conclusion. During the COVID- 19 lockdown period there was a significant reduction in ED attendances and orthopaedic presentations compared to 2019. We also observed that there was a proportional increase in fractures in elderly patients and in minor injuries requiring surgery. These represented the majority of the orthopaedic workload during the lockdown period of 2020. Given this shift towards smaller surgical procedures, we suggest that access to a minor operating theatre in or close to ED would be desirable in the event of a second wave or future crisis

Aims

This study aims to define the epidemiology of trauma presenting to a single centre providing all orthopaedic trauma care for a population of ∼ 900,000 over the first 40 days of the COVID-19 pandemic compared to that presenting over the same period one year earlier. The secondary aim was to compare this with population mobility data obtained from Google.