Aims. Orthopaedic surgeries are complex, frequently performed procedures associated with significant haemorrhage and perioperative blood transfusion. Given refinements in surgical techniques and changes to transfusion practices, we aim to describe contemporary transfusion practices in orthopaedic surgery in order to inform perioperative planning and blood banking requirements. Methods. We performed a retrospective cohort study of adult patients who underwent orthopaedic surgery at four Canadian hospitals between 2014 and 2016. We studied all patients admitted to hospital for nonarthroscopic joint surgeries, amputations, and fracture surgeries. For each surgery and surgical subgroup, we characterized the proportion of patients who received red blood cell (RBC) transfusion, the mean/median number of RBC units transfused, and exposure to platelets and plasma. Results. Of the 14,584 included patients, the most commonly performed surgeries were knee arthroplasty (24.8%), hip arthroplasty (24.6%), and hip fracture surgery (17.4%). A total of 10.3% of patients received RBC transfusion; the proportion of patients receiving RBC transfusions varied widely based on the surgical subgroup (0.0% to 33.1%). Primary knee arthroplasty and hip arthroplasty, the two most common surgeries, were associated with in-hospital transfusion frequencies of 2.8% and 4.5%, respectively. RBC transfusion occurred in 25.0% of hip fracture surgeries, accounting for the greatest total number of RBC units transfused in our cohort (38.0% of all transfused RBC units). Platelet and plasma transfusions were uncommon. Conclusion. Orthopaedic surgeries were associated with variable rates of transfusion. The rate of RBC transfusion is highly dependent on the surgery type. Identifying surgeries with the highest transfusion rates, and further evaluation of factors that contribute to transfusion in identified at-risk populations, can serve to inform perioperative planning and blood bank requirements, and facilitate pre-emptive transfusion mitigation strategies. Cite this article: Bone Jt Open 2021;2(10):850–857

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

Despite the routine use of systemic antibiotic prophylaxis, postoperative infection following fracture surgery remains a persistent issue with substantial morbidity. The use of additional local antibiotic prophylaxis may have a protective effect and some orthopaedic surgeons have adopted their use in recent years, despite limited evidence of its beneficial effect. The purpose of this systematic review and meta-analysis was to evaluate the current literature regarding the effect of prophylactic local antibiotics on the rate of infection in fracture surgery in both open and closed fractures. A comprehensive search of Medline, EMBASE, and PubMed was performed. Cohort studies were eligible if they investigated the effect on infection rate of additional local antibiotic prophylaxis compared with systemic prophylaxis alone following fracture surgery. The data were pooled in a meta-analysis. In total, four randomized controlled trials and 11 retrospective cohort studies with a total of 6161 fractures from various anatomical locations were eligible for inclusion. The majority of the included studies were Level 3 evidence and had a moderate risk of bias. When all fractures were pooled, the risk of infection was significantly reduced when local antibiotics were applied compared with the control group receiving systemic prophylaxis only (OR = 0.39; 95%CI: 0.26 to 0.53, P < 0.001). In particular, there was a significant reduction in deep infections (OR = 0.59; 95%CI: 0.38 to 0.91, P = 0.017). The beneficial effect of local antibiotics for preventing total infection was seen in both open fractures (OR = 0.35; 95%CI: 0.23 to 0.53, P < 0.001) and closed fractures (OR = 0.58; 95%CI: 0.35 to 0.95, P = 0.029) when analyzed separately. This meta-analysis suggests a significant risk reduction for postoperative infection following fracture surgery when local antibiotics were added to standard systemic prophylaxis, with a protective effect present in both open and closed fractures

Abstract. Aim. To identify the difference in infection rates in ankle fracture surgery in Laminar and Non Laminar flow theatres. Background. The infection rates in ankle fracture surgery range between 1–8%. The risk factors include diabetes, alcoholism, smoking, open fractures, osteoporotic fractures in the elderly, and high BMI. Laminar flow has been shown to reduce infections in Arthroplasty surgeries. Therefore, it has become mandatory to use in those procedures. However, it's not the same with ankle fracture surgery. Materials and Methods. It was a retrospective study. The data was collected over a 5 year period between 2015 and 2020. It was collected from Blue spier, Panda, and theatre register. There were 536 cases in each group i.e. Laminar flow (LF) and Non-Laminar flow (NLF). The variables looked at were: 1. Superficial and deep infection rates in LF and NLF theatres, 2. The number of open fractures, 3. Type of ankle fractures (Bimalleolar, Trimalleolar), 4. The number of infected cases who had external fixation prior to ORIF, 5. The number of cases that had Plastics reconstructive procedures, and 6. The grade of the operating surgeon. Conclusions. Superficial infection rate between NLF and LF was not significantly different 11.5% vs 10.3%. The deep infection rate was statistically significant against NLF theatres at 6.34% vs 4.29%. The open fracture was a major contributing factor for deep SSI (14.7% vs 26%). The application of an external fixator in LF and NLF theatres did not alter the infection. rates. Bimalleolar fractures were associated with a higher infection rate

Prolonged bedrest in hospitalized patients is a major risk factor for venous thromboembolism (VTE), especially in high risk patients with hip fracture. Thrombelastography (TEG) is a whole blood viscoelastic hemostatic assay with evidence that an elevated maximal amplitude (MA), a measure of clot strength, is predictive of VTE in orthopaedic trauma patients. The objective of this study was to compare the TEG MA parameter between patients with hip fracture who were more mobile post-operatively and discharged from hospital early to patients with hip fracture with reduced mobility and prolonged hospitalizations post-operatively. In this prospective cohort study, TEG analysis was performed in patients with hip fracture every 24-hours from admission until post-operative day (POD) 5, then at 2- and 6-weeks post-operatively. Hypercoagulability was defined by MA > 65. Patients were divided into an early (within 5-day) and late (after 5-day) discharge group, inpatient at 2-weeks group, and discharge to MSK rehabilitation (MSK rehab), and long term care (LTC) groups. Two-sample t-test was used to analyze differences in MA between the early discharge and less mobile groups. All statistical tests were two-sided, and p-values < 0.05 were considered statistically significant. In total, 121 patients with a median age of 81.0 were included. Patients in the early discharge group (n=15) were younger (median age 64.0) and more likely to ambulate without gait aids pre-injury (86.7%) compared to patients in the late discharge group (n=105), inpatients at 2-weeks (n=48), discharged to MSK rehab (n=30), and LTC (n=20). At two weeks post-operative, the early discharge group was significantly less hypercoagulable (MA=68.9, SD 3.0) compared to patients in the other four groups. At 6-weeks post-operative, the early discharge group was the only group to demonstrate a trend towards mean MA below the MA > 65 hypercoagulable threshold (MA=64.4, p=0.45). Symptomatic VTE events were detected in three patients (2.5%) post-operatively. All three patients had hospitalizations longer than five days after surgery. In conclusion, our analysis of hypercoagulability secondary to reduced post-operative mobility demonstrates that patients with hip fracture who were able to mobilize independently sooner after hip fracture surgery, have a reduced peak hypercoagulable state. In addition, there is a trend towards earlier return to normal coagulation status as determined by the TEG MA parameter. Post-operative mobility status may play a role in determining individualized duration of thromboprophylaxis following hip fracture surgery. Future studies comparing TEG to clinically validated mobility tools may more closely evaluate the contribution of venous stasis due to reduced mobility on hypercoagulation following hip fracture surgery

Prolonged bedrest in hospitalized patients is a major risk factor for venous thromboembolism (VTE), especially in high risk patients with hip fracture. Thrombelastography (TEG) is a whole blood viscoelastic hemostatic assay with evidence that an elevated maximal amplitude (MA), a measure of clot strength, is predictive of VTE in orthopaedic trauma patients. The objective of this study was to compare the TEG MA parameter between patients with hip fracture who were more mobile post-operatively and discharged from hospital early to patients with hip fracture with reduced mobility and prolonged hospitalizations post-operatively. In this prospective cohort study, TEG analysis was performed in patients with hip fracture every 24-hours from admission until post-operative day (POD) 5, then at 2- and 6-weeks post-operatively. Hypercoagulability was defined by MA > 65. Patients were divided into an early (within 5-day) and late (after 5-day) discharge group, inpatient at 2-weeks group, and discharge to MSK rehabilitation (MSK rehab), and long term care (LTC) groups. Two-sample t-test was used to analyze differences in MA between the early discharge and less mobile groups. All statistical tests were two-sided, and p-values < 0.05 were considered statistically significant. In total, 121 patients with a median age of 81.0 were included. Patients in the early discharge group (n=15) were younger (median age 64.0) and more likely to ambulate without gait aids pre-injury (86.7%) compared to patients in the late discharge group (n=105), inpatients at 2-weeks (n=48), discharged to MSK rehab (n=30), and LTC (n=20). At two weeks post-operative, the early discharge group was significantly less hypercoagulable (MA=68.9, SD 3.0) compared to patients in the other four groups. At 6-weeks post-operative, the early discharge group was the only group to demonstrate a trend towards mean MA below the MA > 65 hypercoagulable threshold (MA=64.4, p=0.45). Symptomatic VTE events were detected in three patients (2.5%) post-operatively. All three patients had hospitalizations longer than five days after surgery. In conclusion, our analysis of hypercoagulability secondary to reduced post-operative mobility demonstrates that patients with hip fracture who were able to mobilize independently sooner after hip fracture surgery, have a reduced peak hypercoagulable state. In addition, there is a trend towards earlier return to normal coagulation status as determined by the TEG MA parameter. Post-operative mobility status may play a role in determining individualized duration of thromboprophylaxis following hip fracture surgery. Future studies comparing TEG to clinically validated mobility tools may more closely evaluate the contribution of venous stasis due to reduced mobility on hypercoagulation following hip fracture surgery

Ankle fractures are common orthopedic injuries, often requiring operative intervention to restore joint stability, improve alignment, and reduce the risk of post-traumatic ankle arthritis. However, ankle fracture surgeries (AFSs) are associated with significant postoperative pain, typically requiring postoperative opioid analgesics. In addition to putting patients at risk of opioid dependence, the adverse effects of opioids include nausea, vomiting, and altered mental status which may delay recovery. Peripheral nerve blocks (PNBs) offer notable benefits to the postoperative pain profile when compared to general or spinal anaesthesia alone and may help improve recovery. The primary objective of this quality improvement (QI) study was to increase PNB administration for AFS at our institution to above 50% by January 2021. A root cause analysis was performed by a multidisciplinary team to identify barriers for PNB administration. Four interventions were chosen & implemented: recruitment and training of expert anesthesiologists in regional anesthesia techniques, procurement of additional ultrasound machines, implementation of a dedicated block room with training to create an enhanced learning environment, and the development of an educational pamphlet for patients outlining strategies to manage rebound pain, instructions around the use of oral multimodal analgesia, and the potential for transient motor block of the leg. The primary outcome was the percentage of patients who received PNB for AFS. Secondary outcome measures included total hospitalization length of stay (LOS), post-anesthesia care unit (PACU) and 24-hour postoperative opioid consumption (mean oral morphine equivalent [OME]), proportion of patients requiring opioid analgesic in PACU, and proportion of patients experiencing post-operative nausea and/or vomiting (PONV) requiring antiemetic in PACU. Thirty-day post-operative emergency department (ED) visits were collected as a balance measure. The groups receiving PNB and not receiving PNB included 78 & 157 patients, respectively, with no significant differences in age, gender, or ASA class between groups. PNB administration increased from less than 10% to 53% following implementation of the improvement bundle. Mean total hospital LOS did not vary significantly across the PNB and no PNB groups (1.04 days vs. 1.42 days, P = 0.410). Both mean PACU and mean 24-hour postoperative opioid analgesic consumption was significantly lower in the PNB group compared to the no PNB group (OME in PACU 38.96mg vs. 55.42mg [P = 0.001]; 24-hour OME 44.74mg vs. 37.71mg [P = .008]). A greater proportion of patients in the PNB group did not require any PACU opioid analgesics compared to those in the no PNB group (62.8% vs. 27.4%, P < 0.001). The proportion of patients experiencing PONV and requiring antiemetic both in the PACU did not vary significantly across groups. Thirty-day postoperative ED visits did not vary significantly across groups. By performing a root cause analysis and implementing a multidisciplinary, patient-centered QI bundle, we achieved significant increases in PNB administration for AFS. As a result, there were significant improvements in the recovery of patients following AFS, specifically reduced use of postoperative opioid analgesia. This multi-faceted approach provides a framework for an individualized QI approach to increase PNB administration and achieve improved patient outcomes following AFS

Swelling following an ankle fracture is commonly believed to preclude surgical fixation, delaying operative treatment to allow the swelling to subside. This is in an attempt to achieve better soft tissue outcomes. We aim to identify whether pre-operative ankle swelling influences postoperative wound complications following ankle fracture surgery. This is a prospective cohort study of 80 patients presenting to a tertiary referral centre with operatively managed malleolar ankle fractures. Ankle swelling was measured visually and then quantitatively using the validated ‘Figure-of-eight’ technique. Follow-up was standardised at 2, 6, and 12 weeks post-operatively. Wound complications, patient co-morbidities, operative time, surgeon experience, and hospital stay duration were recorded. The complication rate was 8.75% (n=7), with 1 deep infection requiring operative intervention and all others resolving with oral antibiotics and wound cares. There was no significant difference in wound complication rates associated with quantitative ankle swelling (p=0.755), visual assessment of ankle swelling (p=0.647), or time to operative intervention (p=0.270). Increasing age (p=0.006) and female gender (p=0.049) had a significantly greater probability of wound complications. However, BMI, smoking status, level of the operating surgeon, and tourniquet time were not significantly different. Visual assessment of ankle swelling had a poor to moderate correlation to ‘Figure-of-eight’ ankle swelling measurements ICC=0.507 (0.325- 0.653). Neither ankle swelling nor time to surgery correlates with an increased risk of postoperative wound complication in surgically treated malleolar ankle fractures. Increasing patient age and female gender had a significantly greater probability of wound infection, irrespective of swelling. Visual assessment of ankle swelling is unreliable for quantifying true ankle swelling. Operative intervention at any time after an ankle fracture, irrespective of swelling, is safe and showed no better or worse soft tissue outcomes than those delayed for swelling

Closed ankle fractures have been reported to account for 10% off all fractures presenting to the Emergency Department. Many of these injuries require acute surgical management either via direct admission or through defined outpatient surgical pathways. While both methods have been shown to be safe, few studies have examined the cost effectiveness of each clinical scenario. The purpose of this study is to compare cost and resource utilization associated with inpatient and outpatient ankle fracture surgery at a Canadian academic institution. This is a retrospective chart review of patients who underwent acute ankle fracture surgery at London Health Sciences Centre between 2016 and 2018. Thirty patients who underwent inpatient ankle surgery for closed, isolated ankle fractures at University Hospital were compared to 30 consecutive patients who underwent outpatient ankle surgery for similar fractures at Victoria hospital. Data pertaining to age at time of surgery, sex, BMI, fracture type, operating/recovery room time, and length of hospital stay were collected. All emergency room visits, readmissions and complications within 30 days of surgery were also recorded. Inpatient and outpatient cohorts were similar with respect to average age (48 vs. 44, P=0.326) and body mass index (29.8 vs. 29.1, P=0.741). There was a greater proportion of patients with an American Society of Anesthesia (ASA) Classification of 3 or greater in the inpatient surgery group (48% vs. 23%). The inpatient group spent an average of 1.2 days in hospital while waiting for surgery and a average of 72 hours in hospital for their entire surgical encounter. The outpatient group spent an average of eight days (at home) waiting for surgery while spending an average of 7.4 hours in hospital during their entire surgical encounter. Outpatient ankle fracture surgery was associated with a cost savings of 35.9% in comparison to inpatient ankle fracture surgery (P < 0 .001). There were no significant differences in the rates of emergency room visits, readmissions, or complications between cohorts. Preliminary findings suggest that outpatient ankle fracture surgery is appropriate for most patients, requires less hospital resources and is associated with similar rates of readmission and complications as inpatient surgery. An established outpatient surgical pathway may offer significant cost savings in the treatment of the common closed ankle fracture that requires surgical intervention

One of the more difficult tasks in surgery is to apply the optimal instrument forces and torques necessary to conduct an operation without damaging the tissue of the patient. This is especially problematic in surgical robotics, where force-feedback is totally eliminated. Thus, force sensing instruments emerge as a critical need for improving safety and surgical outcome. We propose a new measurement system that can be used in real fracture surgeries to generate quantitative knowledge of forces/torques applied by surgeon on tissues. We instrumented a periosteal elevator with a 6-DOF load-cell in order to measure forces/torques applied by the surgeons on live tissues during fracture surgeries. Acquisition software was developed in LabView to acquire force/torque data together with synchronised visual information (USB camera) of the tip interacting with the tissue, and surgeon voice recording (microphone) describing the actual procedure. Measurement system and surgical protocol were designed according to patient safety and sterilisation standards. The developed technology was tested in a pilot study during real orthopaedic surgery (consisting of removing a metal plate from the femur shaft of a patient) resulting reliable and usable. As demonstrated by subsequent data analysis, coupling force/torque data with video and audio information produced quantitative knowledge of forces/torques applied by the surgeon during the surgery. The outlined approach will be used to perform intensive force measurements during orthopaedic surgeries. The generated quantitative knowledge will be used to design a force controller and optimised actuators for a robot-assisted fracture surgery system under development at the Bristol Robotics Laboratory

Although wait-times for hip fracture surgery have been linked to mortality and are being used as quality-of-care indicators worldwide, controversy exists about the duration of the wait that leads to complications. Our objective was to use new population-based wait-time data to emprically derive an optimal time window in which to conduct hip fracture surgery before the risk of complications increases. We used health administrative data from Ontario, Canada to identify hip fracture patients between 2009 and 2014. The main exposure was the time from hospital arrival to surgery (in hours). The primary outcome was mortality within 30 days. Secondary outcomes included a composite of mortality or other medical complications (MI, DVT, PE, and pneumonia) also within 30 days. Risk-adjusted cubic splines modeled the probability of each complication according to wait-time. The inflection point (in hours) when complications began to increase was used to define ‘early’ and ‘delayed’ surgery. To evaluate the robustness of this definition, outcomes amongst propensity-score matched early and delayed patients were compared using percent absolute risk differences (% ARDs, with 95% confidence intervals [CIs]). There were 42,230 patients who met entry criteria. Their mean age was 80.1 (±10.7) and the majority were female (70.5%). The risk of complications modeled by cubic splines consistently increased when wait-times were greater than 24 hours, irrespective of the complication considered. Compared to 13,731 propensity-score matched patients who received surgery earlier, 13,731 patients receiving surgery after 24 hours had a significantly higher risk of 30-day mortality (N=898 versus N=790, % ARD 0.79 [95% CI 0.23 to 1.35], p = .006) and the composite outcome (N=1,680 versus N=1,383, % ARD 2.16 [95% CI 1.43 to 2.89], p < .001). Overall, there were 14,174 patients (33.6%) who received surgery within 24 hours and 28,056 patients (66.4%) who received surgery after 24 hours. Increased wait-time was associated with a greater risk for 30-day mortality and other complications. The finding that a wait-time of 24 hours represents a threshold defining higher risk may inform existing hip fracture guidelines. Since two-thirds of patients did not receive surgery within this timeframe, performance improvement efforts that reduce wait-times are warranted

Introduction. Following National patient safety alert on cement use in hip fracture surgery, we investigated the incidence and pattern of 72 hours peri-operative mortality after hip fracture surgery in a District General Hospital. Methods. We reviewed all patients who had hip fracture surgery between 2005-April, 2010. We recorded demographic variables, type of fracture, implant used, medical co-morbidity, seniority of operating surgeon and anaesthetist, peri-operative haemodynamic status, time and cause of death. Results. Over a 64 month period 15 cases were identified. Peri-operative death (PAD) was 1% (15/1402). 4/15 patients died intra-operatively. PAD was highest following Exeter Trauma Stem (ETS) implantation (5/85, 6%) and nil following Bipolar arthroplasty, Austin-Moore arthroplasty (AMA) or Cannulated screw fixation. PAD following total hip arthroplasty was 4% (1/25), Thompson's hemi-arthroplasty 2% (3/191), and Dynamic Hip Screw fixation 1% (6/695). Overall mortality after cemented implant was 2%. ETS implantation led to significantly increased peri-operative mortality compared to AMA (p=0.004). Operations were performed by both trainees (12) and Consultants (3). Both trainees (9) and Consultants (6) anaesthetised the patients. None of the patients belonged to ASA I or II (ASA III 6 and IV 9). All patients had significant cardio-vascular or pulmonary co-morbidity (Ca Lung 2, pulmonary fibrosis 1, end stage COAD 1, AF 6). Cemented implant insertion was followed by immediate haemodynamic collapse and death in 4/15, intra-operative haemodynamic instability in 1/15 and peri-operative instability in 5/15. Post-mortem was performed in 5/15: 2/5 were Pulmonary Embolism (PE), 2/5 bronchopneumonia and 1/5 Myocardial infarction (MI). 4/15 had suspected MI and 1/15 suspected PE. Conclusion. There was 1% risk of peri-operative death after hip fracture surgery. This risk was increased following cemented hemiarthroplasty and highest after ETS implantation. Risk was exacerbated in patients with pre-existing cardiovascular morbidity and independent of the seniority of the surgeon or the anaesthetist

Currently there is an elevated public awareness of the consequences of nosocomial infection, of which, 14.5% is due to surgical site infection (SSI). Hip fracture patients are at increased risk of SSI due to their age related poor medical health, immune response impairments and decreased capacity of wound healing. Superficial SSI following hip fracture surgery can affect up to 16.9% with deep infection affecting 3.7%. Deep infection represents a major complication, from which hip fracture patients are 4.5 times less likely to survive to discharge and carries a 50% mortality at 1 year, compared to 33% without infection. Treatment requires a prolonged hospital stay, additional diagnostic testing, antibiotic therapy and surgery, resulting in the total cost of treating deep infection to be more than double that of non-infected hip fracture surgery. Wound closure aims to accurately appose the skin edges thereby promoting rapid healing and restoration of the protective dermal barrier. Failure to provide accurate skin apposition can result in delayed wound healing which has been shown to have a 3 fold risk of developing late infection. Importantly, delayed wound healing is reflected by prolonged wound ooze. We hypothesized that skin closure via sutures is better at achieving skin edge apposition than wounds closed with staples, providing more rapid wound healing. We compared staples and sutures for wound closure in hip fracture patients by using ooze duration as an outcome measure for wound healing. Duration of wound ooze was recorded in 170 patients. 65 wounds, closed with sutures, had an average duration of ooze of 1.82 days. 105 wounds, closed with staples, had an average duration of ooze of 4.97 days. This study suggests that sutures are superior to staples with regard to early wound healing in hip fracture patients

The aim of this study was to investigate the risk factors, financial costs and outcomes associated with infection after hip fracture surgery. Prospective hip fracture data from the University Hospital, Nottingham, was analysed, assessing patients with either deep or superficial wound infections admitted over a five year period. 3605 patients underwent hip fracture surgery. 2.3% of these patients developed a wound infection of which 1.2% were deep wound infections. 75% of infections were due to Staphylococcus aureus and 50% of all infections were caused by methicillin-resistant Staphylococcus aureus. No statistically significant risk factors for the development of infection were identified in this study. Length of stay, cost of treatment and pre-discharge mortality were all increased with deep infection. Deep wound infection increased the average length of stay from 28 days to 100 days. This quadrupled the ward costs. The mean overall hospital cost of treating a hip fracture complicated by deep wound infection was £34903 compared to £8979 fro those who did not develop infection. Pre-discharge mortality increased from 24.2% in the control group to 30% in the infected group (p<0.006). MRSA significantly increased costs, LOS, and pre-discharge mortality compared with non-MRSA infection. These results show the huge impact that infection after hip fracture surgery has both on mortality and hospital costs

Introduction. Rivaroxaban, an oral factor Xa inhibitor, has been approved by USFDA for prophylaxis of deep vein thrombosis (DVT) and pulmonary embolism (PE) in hip and knee arthroplasties. Its indication in hip fracture surgery has been recently recommended in Asian venous thromboembolism (VTE) guidelines. Phase II dose-ranging study demonstrated that 5 mg rivaroxaban is as effective as enoxaparin for VTE prophylaxis with lower incidence of bleeding complication than the recommended 10 mg dose. Rivaroxaban is recommended to be given 6–8 hours after operation. However, many surgeons are hesitated to follow this guideline since it might increase post-operative blood loss and wound complication. Elderly patients, such as hip fracture patients, are generally at more risk of bleeding and wound complications. These patients may benefit from using the delayed and reduced-dose regimen. Methods. Since July 2011, all eligible hip fracture patients treated by single group of surgeons were given 5mg daily dose of rivaroxaban for VTE prophylaxis. Initial dose of rivaroxaban was given after drain had been removed (24–36 hours post-operatively) and continued for 14 days. Inclusion criteria are femoral neck fracture or intertrochanteric fracture in patients age 60 and over. Exclusion criteria are pathologic fracture, reoperation for failed fixation, chronic anticoagulant therapy, and allergy to rivaroxaban. Criteria by Aniwan and Rojnackarin were used for clinical diagnosis of DVT and PE. Suspected case of DVT and PE were sent for confirmation with Doppler U/S and Pulmonary Artery CT scan, respectively. All bleeding and wound complications were recorded. Numbers of blood transfusion were also recorded. Patients were followed for at least 6 weeks, all complications were recorded. Results. There were 79 hip fracture patients matching our criteria. They were composed of 54 femoral neck fractures and 25 intertrochanteric fractures. Mean age of patients was 76.3 years. All femoral neck fractures were treated with bipolar hemiarthroplasty and intertrochanteric fractures were treated with short cephalomedullary nail. Two patients (2.6%) were compatible with clinical criteria of DVT. However, Doppler ultrasound examinations do not demonstrate thrombus or intraluminal filling defect. There was no suspected case of PE. There was no major hemorrhagic wound complication requiring reoperation. Minor wound complications include 7 (8.9%) cases of prolong serous oozing and 1 (1.3%) superficial wound infection. Extrasurgical site bleeding includes 1 (1.3%) upper GI bleeding and 2 (2.5%) hematuria. None of the patients received more than 2 units of blood transfusion. Discussion and Conclusion. Delayed and reduced-dose regimen of rivaroxaban is effective for VTE prophylaxis in hip fracture patients. There is no major hemorrhagic wound complication. Nonetheless, extrasurgical site bleeding is frequent. Further randomized comparative study with larger number of patients should be performed to demonstrate whether the benefits of the modified regimen existed or not

Hip fracture is associated with highest mortality following trauma in the elderly. The objective of this study is to evaluate the association between duration of anaesthesia and duration of surgery with 30 days mortality following hip fracture surgery. This retrospective cohort study reviewed patients underwent surgery following hip fracture in a district general hospital. Patients less than 65 years, periprosthetic and pathological fractures were excluded. Totally 254 patients were included in the study, who had surgery between February 2005 and September 2008 (20 months period). Mortality details retrieved through National Statistics database. Chi Square tests and Logistic regression analyses were performed to check the relationship between 30 days mortality and all independent variables including duration of anaesthesia and duration of surgery. The incidence of 30 days mortality following hip fracture surgery was 9.4%. The commonest reason of death was cardiac failure and chest infection. Patients who had General anesthesia (GA) had more complications and mortality in comparison with those who had regional anaesthesia. GA increases the odds of 30 days mortality to 2.5 times. Patients under American Society of Anesthesiologists (ASA) II had decreased odds of 30 days mortality than ASA III & IV (odds Ratio 0.16). However duration of anesthesia up to 120 minutes and duration of surgery up to 90 minutes were not associated with 30 days mortality (P>0.05). The 30 days mortality following dynamic hip screw fixation surgery was 14.6% and intra medullary nail was 12.5%. The 30 days mortality in cemented hemi-arthroplasty was 6.9% and uncemented hemi-arthroplasty was 6%. The 30 days mortality was nil in the group of patients who had undergone cannulated hip screw fixation. In elderly people following hip fracture surgery 30 days mortality was not affected by duration of anaesthesia and duration of surgery. However 30 days mortality was related with GA, ASA III & IV and post-operative complications mainly cardiac failure and chest infection. These patients need specialist medical care

Trauma surgeries in the pelvic area are often difficult and prolonged processes that require comprehensive preoperative planning based on a CT scan. Preoperative planning is essential for the appreciation and spatial visualisation of the bone fragments, for planning the reduction strategy, and for determining the optimal type, size, and location of the fixation hardware. We have developed a novel haptic-based patient specific preoperative planning system for pelvic bone fractures surgery planning. The system provides a virtual environment in which 3D bone fragments and fixation hardware models are interactively manipulated with full spatial depth and tactile perception. It supports the choice of the surgical approach and the planning of the two mains steps of bone fracture surgery: reduction and fixation. The purpose of the tool is to provide an intuitive haptic spatial interface for the manipulation of bone fracture 3D models extracted from CT images, to support the selection of bone fragments, the annotation of the fracture surface, the selection and placement of fixation screws, and the creation and placement of fixation plates with an anatomically fit shape. The system incorporates ligament models that constrain the bone fragments motions and provides a realistic interactive fracture reduction support feeling to the surgeon. It allows the surgeon to view the fracture from various directions, thereby allowing fast and accurate fracture reduction planning. Two haptic devices, one for each hand, provide tactile feedback when objects touch without interpenetrating. To facilitate the reduction, the system provides an interactive, haptic fracture surface annotation tool and a fracture reduction algorithm that automatically minimises the pairwise distance between the fracture surfaces. For fracture fixation, the system provides a screw creation and placement capability as well as custom anatomical-fit fixation plate creation and placement. The screw placement is facilitated by the transparent viewing mode that allows the surgeon to navigate the screws inside the bone fragments while constraining them to remain within the bone fragments with haptic forces. Our experimental results with five surgeons show that the method allows highly accurate reduction planning to within 1 mm or less. To evaluate the alignment in terms of quantity, we created a model of an artificial fracture in a healthy pelvis bone. The created model is placed in its anatomic location thus allowing us to measure the error in relation to its initial position. We calculate the anatomic alignment error by measuring the Hausdorff distance in mm between the fragment positioned in the desired location and the fragment placed by the surgeon. The new haptic-based system also supports patient-specific training of pelvic fracture surgeries

The purpose of the study was to identify factors that affect the incidence of deep wound infection after hip fracture surgery. Data from a hip fracture database of 7057 consecutively treated patients at a single centre was used to determine the relationship between deep wound sepsis and a number of factors. Fisher's exact test and the unpaired T test were used. All patients were initially followed up in a specialist clinic. In addition a phone call assessment was made at one year from injury to check that no later wound healing complications had occurred. There were 50 cases of deep infection (rate of 0.7%). There was no significant difference in the rate of deep sepsis with regards to the age, sex, pre-operative residential status, mobility or mental test score of the patient. Specialist hip surgeons and Consultants have a lower infection rate compared with surgeons below Consultant grade, p=0.01. The mean length of anaesthesia was longer in the sepsis group (76minutes) compared to the no sepsis group (65minutes), this was significant, p=0.01. The patient's ASA grade and fracture type were not significant factors. The rate of infection in intracapsular fractures treated by hemiarthroplasty was significantly greater than those that had internal fixation, p=0.001. The rate of infection in extracapsular fractures fixed with an extra-medullary device was significantly greater than those fixed with an intra-medullary device, p=0.021. The presence of an infected ulcer on the same leg as the fracture was not associated with a higher rate of deep infection. In conclusion we have found that the experience (seniority) of the surgeon, the length of anaesthesia and the type of fixation used are all significant factors in the development of deep sepsis. These are all potentially modifiable risk factors and should be considered in the treatment of hip fracture patients

Purpose. Hip fractures are the most common injury requiring hospitalization in both men and women over the age of 65. There is significant mortality associated with hip fracture and delay to surgical treatment increases this rate. We undertook an ethnographic study exploring organizational barriers to timely hip fracture surgery. Method. Using purposive sampling, over 30 interviews were conducted at a large teaching hospital with various professionals involved in the process of getting a patient from ED to surgery and to surgical discharge. This included anaesthetists, surgeons, emergency and internal medicine physicians, nurses, social workers and senior administrative personnel. An additional twelve patient interviews were conducted and reported separately. Following transcription of each tape, a small study team met over the course of several months to read and discuss each transcript in detail. A coding template was developed and each transcript coded with emerging themes noted. Results. Several important themes emerged which impact time to hip fracture surgery. We have classified these as: 1) issues related to inter and intra-professional collaboration; 2) social admissions or “failure to cope” (FTC) patients who are referred to surgical orthopaedic ward beds; 3) difficulties in discharge to rehabilitation; and 4) the disconnect between hospital administration's discourse of efficiency while insufficient resources choke optimal patient flow of care. Conclusion. Inter and intra-professional collaboration has been recognized as central to the provision of excellent, patient-centred care yet not often been studied empirically. Our study revealed obstacles at several stages that stretched from admission at the ED to post-surgical discharge. Tensions were reported between medical, anaesthetic and surgical specialists in relation to consults, anticoagulation and pre-op testing that frustrated attempts to operate within the current Ontario wait time standard of 48 hours. Competition for scarce hospital beds also increased this tension and sense of frustration. In addition, non-operative fracture patients are often referred from ED to orthopaedic surgical wards, thus further delaying access for patients requiring emergent hip fracture surgery due to lack of surgical bed availability. On the basis of these findings our team hopes to advance recommendations designed to address these issues and improve wait times that will be applicable to other hospitals. These recommendations may include the inclusion of a geriatrician or hospitalist on orthopaedic wards as well as harmonized guidelines and care pathways. In addition, we are adding to the understanding of the social organization of acute care in complex and demanding environments

Background. Despite studies into patient consent and their understanding of the potential risks of trauma surgery, no study has looked at the patient's understanding of the procedure involved with neck of femur fracture surgery. Method. Prospective analysis of 150 patients who had operative fixation of neck of femur fractures in a district general hospital. Patients were asked on the third post-operative day to select which procedure they had undergone from a diagram of four different neck of femur surgeries (cannulated screws, cephalomedullary nail, dynamic hip screw and hemiarthroplasty). Exclusion criteria for patient selection - mini mental score of < 20 and confusion secondary to delirium. Results. All patients had signed consent form 1 which was matched to the procedure. All patients were consented by an FP2, CT1 or other SHO. The mean age of patients was 83years. 5% had cannulated screw fixation, 45% had a hemiarthroplasty, 42% had a dynamic hip screw and 8% had a cephalomedullary nail. 47% of patients could correctly identify the procedure they had undergone on the 3. rd. post-operative day. Conclusions. This study shows that there are questions about the effectiveness of informed consent and patient understanding of the procedure before and after hip fracture surgery. We suggest that further detailed studies may highlight the need for alternative ways of communicating procedures to the patients or that more specialised training is required for those explaining hip fracture surgery to patients. Improvements in these areas might help ensure the true informed consent required