The aim of this study was to compare the operating time, length of stay (LOS), adverse events and rate of re-admission for elderly patients with a fracture of the hip treated using either general or spinal anaesthesia. Patients aged ≥ 70 years who underwent surgery for a fracture of the hip between 2010 and 2012 were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Of the 9842 patients who met the inclusion criteria, 7253 (73.7%) were treated with general anaesthesia and 2589 (26.3%) with spinal anaesthesia. On propensity-adjusted multivariate analysis, general anaesthesia was associated with slightly increased operating time (+5 minutes, 95% confidence interval (CI) +4 to +6, p < 0.001) and post-operative time in the operating room (+5 minutes, 95% CI +2 to +8, p < 0.001) compared with spinal anaesthesia. General anaesthesia was associated with a shorter LOS (hazard ratio (HR) 1.28, 95% CI 1.22 to 1.34, p < 0.001). Any adverse event (odds ratio (OR) 1.21, 95% CI 1.10 to 1.32, p < 0.001), thromboembolic events (OR 1.90, 95% CI 1.24 to 2.89, p = 0.003), any minor adverse event (OR 1.19, 95% CI 1.09 to 1.32, p < 0.001), and blood transfusion (OR 1.34, 95% CI 1.22 to 1.49, p < 0.001) were associated with general anaesthesia. General anaesthesia was associated with decreased rates of urinary tract infection (OR 0.73, 95% CI 0.62 to 0.87, p < 0.001). There was no clear overall advantage of one type of anaesthesia over the other, and surgeons should be aware of the specific risks and benefits associated with each type. Cite this article: Bone Joint J 2015; 97-B:689–95

We retrospectively reviewed 183 children with a simple fracture of the distal radius, with or without fracture of the ulna, treated by closed reduction and cast immobilisation. The fracture redisplaced after an initial, acceptable closed reduction in 46 (25%). Complete initial displacement was identified as the most important factor leading to redisplacement. Other contributing factors were the presence of an ipsilateral distal ulnar fracture, and the reduction of completely displaced fractures under deep sedation or local haematoma block. We recommend that completely displaced fractures of the distal radius in children should be reduced under general anaesthesia, and fixed by primary percutaneous Kirschner wires even when a satisfactory closed reduction has been achieved

Objectives. To determine the morbidity and mortality outcomes of patients presenting with a fractured neck of femur in an Australian context. Peri-operative variables related to unfavourable outcomes were identified to allow planning of intervention strategies for improving peri-operative care. Methods. We performed a retrospective observational study of 185 consecutive adult patients admitted to an Australian metropolitan teaching hospital with fractured neck of femur between 2009 and 2010. The main outcome measures were 30-day and one-year mortality rates, major complications and factors influencing mortality. . Results. The majority of patients were elderly, female and had multiple comorbidities. Multiple peri-operative medical complications were observed, including pre-operative hypoxia (17%), post-operative delirium (25%), anaemia requiring blood transfusion (28%), representation within 30 days of discharge (18%), congestive cardiac failure (14%), acute renal impairment (12%) and myocardial infarction (4%). Mortality rates were 8.1% at 30 days and 21.6% at one year. Factors predictive of one-year mortality were American Society of Anesthesiologists (ASA) score (odds ratio (OR) 4.2 (95% confidence interval (CI) 1.5 to 12.2)), general anaesthesia (OR 3.1 (95% CI 1.1 to 8.5)), age > 90 years (OR 4.5 (95% CI 1.5 to 13.1)) and post-operative oliguria (OR 3.6 (95% CI 1.1 to 11.7)). Conclusions. Results from an Australian metropolitan teaching hospital confirm the persistently high morbidity and mortality in patients presenting with a fractured neck of femur. Efforts should be aimed at medically optimising patients pre-operatively and correction of pre-operative hypoxia. This study provides planning data for future interventional studies. Cite this article: Bone Joint Res 2013;2:162–8

Various techniques have been used for the fixation of the posterior pelvis, each with disadvantages specific to the technique. In this study, a new protocol involving the placement of posterior pelvic screws in the CT suite is described and evaluated. A total of 66 patients with unstable pelvic ring injuries was stabilised under local anaesthesia with sedation. The mean length of time for the procedure was 26 minutes per screw. There were no technical difficulties or misplaced screws and no cases of infection or nonunion. All patients stated that they would choose to have the CT scan procedure again rather than a procedure requiring general anaesthesia. The charges for the procedure were approximately £1840 ($2800) per operation. CT-guided placement of iliosacral screws is a safe, feasible, and cost-effective alternative to radiologically-guided placement in the operating theatre in selected patients

Twenty-three patients with thirty hips of slipped capital femoral epiphysis were treated in our department, KK Women's and Children's Hospital, Singapore between 1997 and 2005. Except one patient lost of follow-up, twenty-four SCFEs with more than 2 years (25 to 73 months, average 38.5 months) follow-up were reviewed. This study is to evaluate the effectiveness and outcome of our protocol: Russell traction followed by gentle manipulative reduction with a single screw fixation & spica cast immobilization (for acute-on-chronic cases with unstable and reducible SCFE). In this series, there were 13 boys & 5 girls, mean age 12 year old ranging from 10 to 14 years. Among them 7 were Chinese, 6 Malays & 5 Indians. There were 12 unilateral cases (8 on the left & 4 right, 67%) & 6 bilateral cases (33%), including 2 patients found contralateral SCFE subsequently 1 year postoperatively. Acute-on-chronic SCFE were 16 & chronic SCFE 8. 16 were Grate I & 8 Grate II. Russell traction was on preoperatively with an average of 6 days. Gentle manipulative reduction under general anesthesia was performed in 20 SCFEs (12 GI & 8 GII) and 17 of them were successful. Fixation with a single screw was used for all cases except one hip with 2 screws. Average follow-up was 38.5 months. Good results achieved. All patient were symptom free with good function. No complications of AVN, chondrolysis, screw loosening and reslipping of the affective hips. Our protocol of management for SCFE has been largely successful in term of manipulative reduction and fixation

Aim To develop a militarily relevant complex extremity wounding model. Study Design Controlled laboratory study with New Zealand White Rabbits. Method Phase One: Injury Development. Under general anaesthesia, the flexor carpi ulnaris of the right forelimb was exposed and high energy, short duration impact delivered via drop test rig. Anaesthesia was maintained for three hours, the animal was recovered and saline soaked gauze and supportive bandaging applied. 48 hrs later, the animal was culled and muscle harvested for histological analysis. Analgesia was administered daily, animals checked by experienced staff at least twice daily and temperatures recorded by subcutaneous transponder. Phase Two: Contamination. Sequential groups of animals had inoculums of 1×102, 1×106 and 1×108/100μl of Staphylococcus aureus administered to the muscle immediately after injury. Animals were recovered as phase one. At 48 hours, animals were culled, muscle harvested and axillary lymph nodes sampled. Quantitative microbiological analysis was performed on the muscle. Results: Six animals given a loading of 0.5kg yielded consistent injury with 20% of the muscle becoming necrotic. Representative of injury from ballistic trauma, this was adopted as standard. Twenty-two subsequent animals were exposed to the injury and inoculated with the challenge doses. 1×106/100μl S.aureus provided the greatest consistency in recovered yield. There were no adverse effects on animal welfare and body temperatures were always within normal limits. Discussion. This model enables a consistent, contaminated soft tissue injury to be delivered in vivo. It will allow the investigation of complex wound management including wound coverage and fracture fixation

Introduction. The role of in-situ decompression in patients with severe ulnar nerve compression is still controversial. The authors present a prospective study on the results of in-situ decompression in this selected group of patients treated through a mini open incision (4cms) and complete decompression by appropriate patient positioning. Material/Methods. Thirty patients (20 Male/10 Female) with severe degree of nerve compression, confirmed clinically by Dellon's classification and by abnormal Nerve Conduction Study, underwent simple in-situ decompression under general anaesthesia as a day-case procedure. Through a 4cms incision and by moving the elbow the nerve is fully visualised and decompressed. Outcome was measured prospectively at three months and one year using Modified Bishop's score, grip strengths and two point discrimination (2PD). Results/Statistics. The average age of patients were 58.3 (26–87) and dominant hand was involved in 13 patients. Patients showed improvement greater at 1year than at 3 months. There was statistically significant improvement in power (p-0.01) and pinch grip strength (p-0.001) at one year after surgery. According to Modified Bishop's scoring, 24 patients (80%) had good to excellent results at one year follow-up. Of the eight patients with fair results at three months four improved and two detiorated, leading to a total of four poor results (13.3%) at one year follow-up. The 2PD identified the patients with poor or good results according to the Modified Bishop score at three months follow-up. Conclusions. Our results show that the minimally invasive in-situ decompression is technically simple, safe and gives good results in patients with severe nerve compression. The Modified Bishop score and 2PD were more reliable in assessing these patients at follow-up

Background. The degree of postoperative pain is usually moderate to severe following Total Hip Arthroplasty (THA). Comfort and lack of pain are important for optimal mobilization and earlier home discharge. Aim. To evaluate the efficacy and safety of Ropivacaine, a long- acting local anaesthetic, when infiltrated in the wound at the end of operation of THA. Methods. Seventy patients, 39 women and 31 men, ASA I-III, underwent Total Hip Arthroplasty in our clinic from January 2008 to June 2009. Patients were randomized into two groups. In group A, a solution of 100 ml Ropivacaine 2mg/ml (Naropeine 0,2%) was infiltrated in the deep tissues (capsule, gluteus medius, gluteus maximus and rotators) (50 ml) while the fascia, subcutaneous tissues and skin were infiltrated with the remaining 50ml. Group B was the control group. All patients received standardized general anesthesia or spinal anesthesia and a PCA morphine using a self-administered pain pump was applied in the recovery room for 48 hours. All patients took 1gr x 3 Apotel i.v., 40mg x2 Dynastat i.v., and 4mg x2 Zofron i.v. for 48 hours postoperative. Pain scores with Visual Analogue Scale (0–10) at 1, 2, 4, 8, 12, 24 and 48 hours postoperatively, time to the first analgesic requirement and side effects were recorded. Results. There were no significant differences in demographic characteristics of the patients and duration of the surgery between two groups. Morphine consumption was statistically significantly lower in group A for the first 48 hours, resulting in a lower frequency of nausea, itching and sedation. Postoperative pain levels at rest and during mobilization were statistically significantly lower in group A while median hospital stay was similar in both groups. Conclusion. Operative wound infiltration with ropivacaine reduces pain and the requirement for analgesics after hip replacement, leading to faster postoperative mobilization

Purpose of this study is to create an experimental model of electrophysologic evaluation of the supraspinatus muscle on rats, after traumatic rupture of its tendon. The population of this study consisted of 10 male Sprague Dawley rats weighting 300–400g. Under general anaesthesia we proceeded with traumatic rupture of the supraspinatus tendon and exposure of the muscle. The scapula was immobilized, and the supraspinatus tendon was attached to a force transducer using a 3–0 silk thread. A dissection was performed in order to identify the suprascapular nerve, which was then stimulated with a silver electrode. Stimulations were produced by a stimulator (Digitimer Stimulator DS9A) and were controlled by a programmer (Digitimer D4030). Fiber length was adjusted until a single stimulus pulse elicited maximum force during a twitch under isometric conditions. Rectangular pulses of 0.5 ms duration were applied to elicit twitch contractions. During the recordings, muscles were rinsed with Krebs solution of approximately 37 8C (pH 7.2–7.4) and aerated with a mixture of 95% O2 and 5% CO2. The output from the transducer was amplified and recorded on a digital interface (CED). The following parameters were measured at room temperature (20–21 8C): single twitch tension; time to peak; half relaxation time; tetanic tensions at 10, 20, 40, 80 and 100 Hz; and fatigue index, which was evaluated using a protocol of low frequency (40 Hz) tetanic contraction, during 250 ms in a cycle of 1 s, for a total time of 180 s. The fatigue index value was then calculated by the formula [fatigue index=(initial tetanic tension − end tetanic tension) ∗ 100/(initial tetanic tension)]. In the end, the transducer was calibrated with standard weights and tensions were converted to grams. The mean single twitch was 8.2, the time to peak 0.034 msec and the half relaxation time 0.028 msec. The strength of titanic muscle contractures was 5.7 msec at 10Hz and 17.7 at 100Hz. Finally, the fatigue index was calculated at 48.4. We believe that electrophysiologic evaluation of the supraspinatus muscle in rats will help us understanding the pathology of muscle atrophy after rotator cuff tears and possibly the functional restoration after cuff repair

Objective. To assess the beneficial use of polypropylene mesh impregnated with vancomycin in an experimental model open fractures Gustilo IIIa in rabbits. Material and Method. We worked with 15 New Zeland White rabbits. All of them were carried out under general anaesthetic, a 5-cm incision longitudinal was made at the back of the right thigh. The femur was aproached and a fracture was performed with a shear, giving rise to a multifragment fracture. The wound remained open for 6 hours with the bone exposed, in a non-surgical ambient. Subsequently underwent surgical cleaning of the open fractures in two stages. The fracture was stabilized with an intramedular pin. The animals were sorted in 3 different therapeutic groups:. Group 1: (5 rabbits) without other treatment. Group 2: (5 rabbits) a polypropylene mesh was placed around the fracture. Group 3: (5 rabbits) a polypropylene mesh with vancomycin was placed around the fracture. The wound was closed with nylon stiches. Three weeks postoperative, the animals were intervened surgically under general anesthesia, after aseptic cure and placement of surgical fields, femoral bone biopsies, soft tissue and mesh were taken. The rabbits were sacrified. The samples were sent to pathology and bacteriology labs. Results. The bacteria isolated were as follows: Escherichia coli, Pasteurella multocida, Staphylococcus spp., Clostridium spp. Mamheinia spp. The Clostridium spp. is a common contaminant in the exposed fractures present in the environment. The Pasteurella mustocida is a microorganism present in the oral cavity of rabbits, as well as Escherichia coli is a germ present in the animal's digestive tract. Mannheimia spp. It is a beta-hemolytic organism, found in the nasal flora of these animals and their pathological role is not elucidated. Staphylococcus spp. is a germ that is found in the normal flora of the animals skin. Group 1 showed a relative risk for an infection. For Group 2 the relative risk was substantially greater than 1.4, while in Group 3, the relative risk was 0.6, significantly lower than the previous two groups. The results have shown a beneficial effect of the use of impregnated polypropylene mesh with vancomycin in this animal group. Conclusion. The use of polypropylene meshes with vancomycin could be useful in the treatment of muscle and ligamentary deficits in patients with open fractures Gustillo IIIa

Hip fracture treatment strategies continue to evolve with the goal of restoring hip fracture victims to Pre-injury Functional levels. Strategies for improved treatment have focused on fracture exposure, reduction, provisional fixation and definitive fixation with implant designs optimised for fracture union with minimal implant failure as originally proposed by Lambotte. Multiple implant designs have been conceived based on perceived inadequacies of previous generational designs. To better understand this evolutionary process, it is necessary to review the predecessors of modern fracture treatment and understand their design concepts and results. It is interesting that the modern era of surgical treatment of hip fractures actually began in 1902, when Dr Royal Whitman advocated the necessity of a closed reduction of adult hip fractures under general anesthesia and stabilisation by hip spica cast. Dr Whitman predicted the evolution of stabilisation by internal fixation and commented on this in his 1932 JBJS editorial emphasising the importance of surgical treatment of fractures. Dr Smith-Peterson, also from New York, in 1925 developed the 1st commercially successful hip implant, a tri–flanged nail. These first surgeries were performed with an open reduction, through a Smith-Petersen approach without radiographic control. This nail device was rapidly modified in the 1930's to permit insertion over a guide wire with a radiographic controlled insertion technique, a minimally invasive procedure. Nail penetration and implant failure in pertrochanteric fractures led to the rapid development of side-plates and a refocus on reduction stability. This led to a period of primary corrective osteotomies for enhanced stability, but fell out of failure after the sliding hip screw concept took hold. Originally conceived by Godoy-Moreira and Pohl independently in the 1940s, it became rapidly accepted as a method to avoid nail penetration and implant failure, unfortunately at the expense of accepting malunion and collapse of the fracture. Even the importance of rotational stability was discarded as insignificant by Holt in 1963. The concept of reduction of the Antero-Medial cortex was forgotten in favour of the Tip-apex distance as the only important variable in reduction to avoid implant cut-out. The concept of malunion of pertrochanteric fractures was simply deleted from consideration with disregard for the possible association of impaired functional recovery. Several recent papers that improved functional recovery is possible when these new implants are coupled with successful reduction strategies. Further studies are needed to identify the correct choice of implant for the appropriate fracture configuration, which may lead to a revision of our current fracture classification systems and our concepts of stability

Introduction. The peri-operative analgesic management of patients having either Total Knee Replacement (TKR) or Unicompartmental Knee Replacement (UKR) is an area that continues to have prominence, driven in part by the desire to reduce hospital stay, while maintaining high patient satisfaction. This is particularly relevant in the current climate of healthcare cost savings. We evaluated the role of “top up” intra-articular local anaesthetic injection after identifying that an appreciable number of patients in the unit suffered “breakthrough pain” on the first post-op day, when the effects of local analgesia are wearing off. Method. 43 patients, who were scheduled to have a cemented Oxford UKR, were prospectively recruited and randomised. All patients had the same initial anaesthetic regime of general anaesthesia, femoral nerve block and intra-operative intra-articular infiltration of the cocktail. All patients had a 16G multi-holed epidural catheter placed intra-articularly prior to wound closure. Patients had the same operative technique, post operative rehabilitation and rescue analgesia. An independent observer recorded post-operative pain scores using a visual analogue score (1–10) every 6 hours and any rescue analgesia that was required. On the morning after surgery, 22 patients, (Group I), received 20 mls of 0.5% bupivicaine through the catheter whilst 21 patients, (Group II), had 20 mls of normal saline by the same observer, (who was blinded to the contents of the solution being injected), after which the catheter was removed. Results. When comparing these two groups there was no statistical difference found in their pain scores on the day of operation. However, patients in Group I had a significantly better pain score initially post top up and then at 6 hours (2.4 (0–8) vs 5.7 (2–9), Mann-Whitney p<0.001). This cohort of patients required less rescue analgesia (22% vs 75%, Mann-Whitney p<0.001). In addition, Group I had statistically significant higher patient satisfaction outcome scores after the infiltration, (p<0.001), with 16 reporting very good satisfaction in comparison to 1 in Group II. There were no complications in either group. Discussion. Our study has shown that injection of local anaesthesia via an intra-articular catheter does reduce pain scores when compared to placebo. This implies that this technique may have a role in providing optimal pain relief after UKR

Background. It is unclear which form of anaesthesia is the most favourable in primary total hip replacement (THR) surgery. A recently published systematic review of modern anaesthesia techniques in primary THR surgery (Macfarlane 2009) was not able to show any convincing benefit of regional or general anaesthesia. One retrospective study that examined anaesthesia and leg length (Sathappan 2008), found an increased incidence of leg length difference > 5 mm in those patients who were operated with regional anaesthesia. Our department used a mini invasive approach in supine as standard procedure in THR. The type of anaesthesia that is chosen is up to the individual anaesthetist. Purpose. We wanted to see if there was any correlation between type of anaesthesia and leg length, total time spent in theatre and recovery room, postoperative hospital stay, blood loss or operating time in primary THR surgery with a mini invasive approach in supine. Materials and Methods. Our study was a retrospective study of 170 primary THR patients. All patients received an uncemented Corail stem and a cemented Marathon cup. Patients with abnormal anatomy, BMI > 46, simultaneous removal of internal fixation or incomplete data were excluded in the analysis. Radiograpic leg length was measured using the inter teardrop line and the lesser trochanter. Results. 99 patients were operated on with spinal anaesthesia and 71 with total intravenous anaesthesia (TIVA). There were 65% women in both groups. Average age was 74 years (32–95) in the spinal anaesthesia group and 67 years (38–93) in the TIVA group. We found no significant difference in the average operating time (spinal 65 min, TIVA 64 min), drop in haemoglobin to the first postoperative day (spinal 16%, TIVA 16%), postoperative hospital stay (Spinal 1.4 days, TIVA 1.4) or in transfusion rate (spinal 1%, TIVA 1.4%). We found a significant difference in the proportion of patients with a leg length difference of more than 7 mm (Spinal 22%, TIVA 6%, p = 0.02) and the average total time spent in theatre and post-operative department (spinal 325 min, TIVA 293 min, p < 001). Discussion. The study is retrospective and is therefore fettered by the limitations inherent in such a study. Our study seems to confirm the earlier findings that the type of anaesthesia can affect leg length in primary THR. It is speculated that spinal anaesthesia has a more unpredictable effect on muscular tension which could explain this

Background. Thromboembolic disease is a common complication of total hip replacement (THR). The administration of postoperative anticoagulants is therefore highly recommended. The purpose of this study was to compare rivaroxaban with fondaparinux with regards to their safety and effectiveness for the prevention of venous thromboembolic events (VTE) after THR. Methods. We conducted an independent prospective study comparing VTE prevention strategies in two successive series of patients (Groups A and B) undergoing elective unilateral THR. Group A (n=253) received fondaparinux daily 2.5 mg for 10 days, followed by tinzaparin 4500 IU daily for one month. Group B (n=229) received 10 mg rivaroxaban daily for 40 days without platelet monitoring. All surgeries were performed by a single surgeon under general anesthesia using an active blood transfusion-sparing plan. In the absence of contraindications, patients received intra-operative administration of tranexamic acid to reduce postoperative bleeding. Preoperative and postoperative hemoglobin levels were recorded at regular intervals. Bleeding events were documented. The bleeding index was calculated by adding the number of red blood cell units and the difference in the hemoglobin level (in g/dL) between the first morning after the day of surgery and the seventh postoperative day (POD 7). After 5 to 10 days, all patients underwent bilateral lower-extremity duplex ultrasonography to screen for deep venous thrombi. Any clinical symptoms of pulmonary embolism were evaluated with spiral computed tomography lung scans. Clinical evaluation to look for evidence of deep venous thrombi and pulmonary emboli was performed at eight weeks postoperatively. Results. Baseline characteristics between the two groups were comparable. The rate of major bleeding events, proximal deep venous thrombi, and pulmonary emboli was nil in each group. The incidence of blood transfusion was 0.8% in Group A (2 of 253 hips) and 0.4% (1 of 229 hips) in Group B (p=1.0). The bleeding index analysis excluded 8 hips for which the hemoglobin value at POD 7 was not measured. The bleeding index was 1.03 (standard deviation, 0.88) in Group A and 0.8 (standard deviation, 0.80) in Group B (p<0.001). The incidence of bleeding index >2 was 10.5% (27 of 247 hips) in Group A and 3% (7 of 227 hips) in Group B (p<0.001). Discussion. We compared two series of patients treated with THR undertaken with postoperative anticoagulation to prevent VTE. The high level of success these anticoagulant treatments had at preventing VTE in our series could be attributed at least partially to the combination of an active blood-sparing transfusion plan with the use of anticoagulant molecules reported in the literature to be quite potent. Conclusions. This prospective study comparing two anticoagulant regimens in patients treated with THR did not detect any difference with regards to the efficacy of the treatments, although there was significantly less bleeding index in patients who received rivaroxaban

Aims

The aim of this study was to compare the early postoperative mortality and morbidity in older patients with a fracture of the femoral neck, between those who underwent total hip arthroplasty (THA) and those who underwent hemiarthroplasty.

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The aim of this study was to investigate the association between additional rehabilitation at the weekend, and in-hospital mortality and complications in patients with hip fracture who underwent surgery.

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The use of multimodal non-opioid analgesia in hip fractures, specifically acetaminophen combined with non-steroidal anti-inflammatory drugs (NSAIDs), has been increasing. However, the effectiveness and safety of this approach remain unclear. This study aimed to compare postoperative outcomes among patients with hip fractures who preoperatively received either acetaminophen combined with NSAIDs, NSAIDs alone, or acetaminophen alone.

Aims

Hip fracture commonly affects the frailest patients, of whom many are care-dependent, with a disproportionate risk of contracting COVID-19. We examined the impact of COVID-19 infection on hip fracture mortality in England.

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The purpose was to compare operative treatment with a volar plate and nonoperative treatment of displaced distal radius fractures in patients aged 65 years and over in a cost-effectiveness analysis.

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Hospital case volume is shown to be associated with postoperative outcomes in various types of surgery. However, conflicting results of volume-outcome relationship have been reported in hip fracture surgery. This retrospective cohort study aimed to evaluate the association between hospital case volume and postoperative outcomes in patients who had hip fracture surgery. We hypothesized that higher case volume would be associated with lower risk of in-hospital and one-year mortality after hip fracture surgery.