Aims

The aims of this study were to describe the demographic, socioeconomic, and educational factors associated with core surgical trainees (CSTs) who apply to and receive offers for higher surgical training (ST3) posts in Trauma & Orthopaedics (T&O).

Heterotopic ossification (HO) is a well-known complication of traumatic elbow injuries. The reported rates of post-traumatic HO formation vary from less than 5% with simple elbow dislocations, to greater than 50% in complex fracture-dislocations. Previous studies have identified fracture-dislocations, delayed surgical intervention, and terrible triad injuries as risk factors for HO formation. There is, however, a paucity of literature regarding the accuracy of diagnosing post-traumatic elbow HO. Therefore, the purpose of our study was to determine the inter-rater reliability of HO diagnosis using standard radiographs of the elbow at 52 weeks post-injury, as well as to report on the rate of mature compared with immature HO. We hypothesized inter-rater reliability would be poor among raters for HO formation. Prospectively collected data from a large clinical trial was reviewed by three independent reviewers (one senior orthopedic resident, one senior radiology resident, and one expert upper extremity orthopedic surgeon). Each reviewer examined anonymized 52-week post-injury radiographs of the elbow and recorded: 1. the presence or absence of HO, 2. the location of HO, 3. the size of the HO (in cm, if present), and 4. the maturity of the HO formation. Maturity was defined by consensus prior to image review and defined as an area of well-defined cortical and medullary bone outside the cortical borders of the humerus, ulna, or radius. Immature lesions were defined as an area of punctate calcification with an ill-defined cloud-like density outside the cortical borders of the humerus, ulna or radius. Data were collected using a standardized online data collection form (CognizantMD, Toronto, ON, CA). Inter-rater reliability was calculated using Fleiss’ Kappa statistic and a multivariate logistic regression analysis was performed to identify risk factors for HO formation in general, as well as mature HO at 52 weeks post injury. Statistical analysis was performed using RStudio (version1.4, RStudio, Boston, MA, USA). A total of 79 radiographs at the 52-week follow-up were reviewed (54% male, mean age 50, age SD 14, 52% operatively treated). Inter-rater reliability using Fleiss’ Kappa was k= 0.571 (p = 0.0004) indicating moderate inter-rater reliability among the three reviewers. The rate of immature HO at 52 weeks was 56%. The multivariate logistic regression analysis identified male sex as a significant risk factor for HO development (OR 5.29, 1.55-20.59 CI, p = 0.011), but not for HO maturity at 52 weeks. Age, time to surgery, and operative intervention were not found to be significant predictors for either HO formation or maturity of the lesion in this cohort. Our study demonstrates moderate inter-rater reliability in determining the presence of HO at 52 weeks post-elbow injury. There was a high rate (56%) of immature HO at 52-week follow-up. We also report the finding of male sex as a significant risk factor for post traumatic HO development. Future research directions could include investigation into possible male predominance for traumatic HO formation, as well as improving inter-rater reliability through developing a standardized and validated classification system for reporting the radiographic features of HO formation around the elbow

The aim of this study was to determine the floor and ceiling effects for both the QuickDASH and PRWE following a fracture of the distal radius. Secondary aims were to determine the degree to which patients with a floor or ceiling effect felt that their wrist was ‘normal’, and if there were patient factors associated with achieving a floor or ceiling effect. A retrospective cohort study of patients sustaining a distal radius fracture and managed at the study centre during a single year was undertaken. Outcome measures included the QuickDASH, the PRWE, EuroQol-5 Dimension-3 Levels (EQ-5D-3L), and the normal wrist score. There were 526 patients with a mean age of 65yrs (20–95) and 421 (77%) were female. Most patients were managed non-operatively (73%, n=385). The mean follow-up was 4.8yrs (4.3–5.5). A ceiling effect was observed for both the QuickDASH (22.3%) and PRWE (28.5%). When defined to be within the minimum clinical important difference of the best available score, the ceiling effect increased to 62.8% for the QuickDASH and 60% for the PRWE. Patients that achieved a ceiling score for the QuickDASH and PRWE subjectively felt their wrist was only 91% and 92% normal, respectively. On logistic regression analysis, a dominant hand injury and better health-related quality of life were the common factors associated with achieving a ceiling score for both the QuickDASH and PRWE (all p<0.05). The QuickDASH and PRWE demonstrate ceiling effects when used to assess the outcome of fractures of the distal radius. Patients achieving ceiling scores did not consider their wrist to be ‘normal’. Future patient-reported outcome assessment tools for fractures of the distal radius should aim to limit the ceiling effect, especially for individuals or groups that are more likely to achieve a ceiling score

Abstract. Introduction. There is paucity of evidence in predicting outcomes following cervical decompression in patients in octogenerians with cervical myelopathy. Our aim is to analyse the predictive value of Charlson comorbidity index (CCI) on clinical outcomes in this group. Methods. All patients age >80 years who underwent cervical decompression+/−stabilisation between January 2006-December 2021 at University Hospitals of Derby & Burton were included. Logistic regression analysis was performed using JASP. Results. Total 72 patients (n=32 male, n=28 female). Mean age 83.44 ± 3.21 years. 67 patients underwent posterior decompression+ stabilisation & 5 patients had posterior decompression alone. Mean CCI was 5; graded moderate in 32 (44%, CCI=<4) and severe in 40 (55.5%, CCI>4). Mean age and preoperative Nurick grade was similar between moderate and severe groups. Postoperative Nurick grade improved equally in both groups by 0.67 and 0.68 respectively (p=0.403). Mean LOS 16±16.12 days. 5 complications in the moderate group (21.8%) and 8 complications in severe group (21.6%); wound infection (n=7), other infection (n=2), electrolyte derangement (n=2), AKI (n=1), blood transfusion (n=1) and early death (n=3) (p=0.752). 1 early postoperative death <30 days occurred in the moderate group (4.3%) whereas 2 occurred in the severe group (5.3%) (p=0.984). No patients with moderate CCI required nursing home discharge whereas 7.9% of severe patients required this. Conclusion. Both groups benefitted from neurological improvement postoperatively, low 1 year mortality. No difference in hospital stay, complication rate and early mortality between both groups. More patients with severe CCI require nursing care after discharge than those with moderate CCI

It is undetermined which factors predict return to work following arthroscopic rotator cuff repair. We aimed to identify which factors predicted return to work at any level, and return to pre-injury levels of work 6 months post-arthroscopic rotator cuff repair. Multiple logistic regression analysis of prospectively collected demographic, pre-injury, preoperative, and intraoperative data from 1502 consecutive primary arthroscopic rotator cuff repairs, performed by a single surgeon, was performed to identify independent predictors of return to work, and return to pre-injury levels of work respectively, 6 months post-surgery. Six months post-rotator cuff repair, 76% of patients returned to work (RTW), and 40% returned to pre-injury levels of work (Full-RTW). RTW at 6 months was likely if patients were still working after their injuries, but prior to surgery (Wald statistic [W]=55, p<0.0001), were stronger in internal rotation preoperatively (W=8, p=0.004), had full-thickness tears (W=9, p=0.002), and were female (W=5, p=0.030). Patients who achieved Full-RTW were likely to have worked less strenuously pre-injury (W=173, p<0.0001), worked more strenuously post-injury but pre-surgery (W=22, p<0.0001), had greater behind-the-back lift-off strength preoperatively (W=8, p=0.004), and had less passive external rotation range of motion preoperatively (W=5, p=0.034). Patients who were still working post-injury, but pre-surgery were 1.6-times more likely to RTW than patients who were not (p<0.0001). Patients who nominated their pre-injury level of work as “light” were 11-times more likely to achieve Full-RTW than those who nominated “strenuous” (p<0.0001). Six months post-rotator cuff repair, a higher patient-rated post-injury, but pre-surgery level of work was the strongest predictor of RTW. A lower patient-rated pre-injury level of work was the strongest predictor of Full-RTW. Greater preoperative subscapularis strength independently predicted both RTW, and Full-RTW

The use of cannabis is increasingly medically relevant as it is legalized and gains acceptance more broadly. However, the effects of marijuana use on postoperative outcomes following orthopedic surgery have not been well-characterized. This study seeks to illuminate the relationship between marijuana use and the incidence postoperative complications including: DVT, PE, nonunion, and infection following common orthopedic procedures. This study was conducted using a national orthopaedic claims insurance database. We identified all patients undergoing knee arthroscopy, shoulder arthroscopy, operatively managed long bone fractures (humerus, femur, tibia and/or fibula, and radius and/or ulna), and single-level lumbar fusion. The proportion of patients within each surgery cohort who had a diagnostic code for marijuana dependence was assessed. The rates of DVT, PE, and infection within 90 days were assessed for all patients. The rate of nonunion was assessed for the long bone fracture and lumbar fusion cohorts. Univariate analyses of marijuana dependence on all outcomes were performed, followed by a multivariate logistic regression analysis controlling for known patient comorbidities. We identified 1,113,944 knee arthroscopy, 747,938 shoulder arthroscopy, 88,891 lumbar fusion, and 37,163 long bone fracture patients. Out of the 1,987,936 patients, 24,404 patients had a diagnostic code for marijuana dependence. Within all four surgical subgroups, the marijuana dependence cohort experienced increased rates of infection, PE, and DVT, as well as increased rates of nonunion in the lumbar fusion and long bone fracture populations. In the multivariate analyses controlling for a variety of patient risk factors including tobacco use, marijuana dependence was identified as an independent risk factor for infection within all four surgical subgroups (Knee: OR 1.85, p < 0.001; Shoulder: OR 1.65, p < 0.001; Spine: OR 1.45, p < 0.001; Long bone: OR 1.28, p < 0.001), and for nonunion in the lumbar fusion (OR 1.38, p < 0.001) and long bone fracture (OR 1.31, p < 0.001) subgroups. Our data suggests that marijuana dependence may be associated with increased rates of infection and nonunion following a variety of orthopaedic procedures. During preoperative evaluation, surgeons may consider marijuana use as a potential risk factor for postoperative complications, especially within the context of marijuana legalization. Future research into this relationship is necessary

Distal radius fractures (DRFs) are common injuries that represent 17% of all adult upper extremity fractures. Some fractures deemed appropriate for nonsurgical management following closed reduction and casting exhibit delayed secondary displacement (greater than two weeks from injury) and require late surgical intervention. This can lead to delayed rehabilitation and functional outcomes. This study aimed to determine which demographic and radiographic features can be used to predict delayed fracture displacement. This is a multicentre retrospective case-control study using radiographs extracted from our Analytics Data Integration, Measurement and Reporting (DIMR) database, using diagnostic and therapeutic codes. Skeletally mature patients aged 18 years of age or older with an isolated DRF treated with surgical intervention between two and four weeks from initial injury, with two or more follow-up visits prior to surgical intervention, were included. Exclusion criteria were patients with multiple injuries, surgical treatment with fewer than two clinical assessments prior to surgical treatment, or surgical treatment within two weeks of injury. The proportion of patients with delayed fracture displacement requiring surgical treatment will be reported as a percentage of all identified DRFs within the study period. A multivariable conditional logistic regression analysis was used to assess case-control comparisons, in order to determine the parameters that are mostly likely to predict delayed fracture displacement leading to surgical management. Intra- and inter-rater reliability for each radiographic parameter will also be calculated. A total of 84 age- and sex-matched pairs were identified (n=168) over a 5-year period, with 87% being female and a mean age of 48.9 (SD=14.5) years. Variables assessed in the model included pre-reduction and post-reduction radial height, radial inclination, radial tilt, volar cortical displacement, injury classification, intra-articular step or gap, ulnar variance, radiocarpal alignment, and cast index, as well as the difference between pre- and post-reduction parameters. Decreased pre-reduction radial inclination (Odds Ratio [OR] = 0.54; Confidence Interval [CI] = 0.43 – 0.64) and increased pre-reduction volar cortical displacement (OR = 1.31; CI = 1.10 – 1.60) were significant predictors of delayed fracture displacement beyond a minimum of 2-week follow-up. Similarly, an increased difference between pre-reduction and immediate post reduction radial height (OR = 1.67; CI = 1.31 – 2.18) and ulnar variance (OR = 1.48; CI = 1.24 – 1.81) were also significant predictors of delayed fracture displacement. Cast immobilization is not without risks and delayed surgical treatment can result in a prolong recovery. Therefore, if reliable and reproducible radiographic parameters can be identified that predict delayed fracture displacement, this information will aid in earlier identification of patients with DRFs at risk of late displacement. This could lead to earlier, appropriate surgical management, rehabilitation, and return to work and function

Aim. Whether laminar airflow (LAF) in the operating room (OR) is effective for decreasing periprosthetic joint infection (PJI) following total joint arthroplasty (TJA) remains a clinically significant yet controversial issue. This study investigated the association between operating room ventilation systems and the risk of PJI in TJA patients. Method. We performed a retrospective observational study on consecutive patients undergoing primary total knee arthroplasty (TKA) and total hip arthroplasty (THA) from January 2013-September 2017 in two surgical facilities within a single institution, with a minimum 1-year follow-up. All procedures were performed by five board-certified arthroplasty surgeons. The operating rooms at the facilities were equipped with LAF and turbulent ventilation systems, respectively. Patient characteristics were extracted from clinical records. PJI was defined according to Musculoskeletal Infection Society criteria within 1-year of the index arthroplasty. A multivariate logistic regression model was performed to explore the association between LAF and risk of 1-year PJI, and then a sensitivity analysis using propensity score matching (PSM) was performed to further validate the findings. Results. A total of 6,972 patients (2,797 TKA, 4,175 THA) were included. The incidence of PJI within 1 year for patients from the facility without laminar flow was similar at 0·4% to that of patients from the facility with laminar flow at 0·5%. In the multivariate logistic regression analysis, after all confounding factors were taken into account, the use of LAF was not significantly associated with reduction of the risk of PJI. After propensity score matching, there was no significant difference in the incidence of PJI within 1 year for patients between the two sites. Conclusions. The use of LAF in the operating room was not associated with a reduced incidence of PJI following primary TJA. With an appropriate perioperative protocol for infection prevention, LAF does not seem to play a protective role in PJI prevention

Purpose. The hip fracture has been increasing as the aging population continues to grow. Hip fracture patients are more susceptible to blood loss and venous thromboembolism (VTE). The objective of this study was to assess the efficacy and safety of tranexamic acid (TXA) in fracture patients undergoing fast-track hemiarthroplasty. Methods. 609 hip fracture patients undergoing hemiarthropalsty from January 2013 to September 2016 were prospectively selected. 289 patients received 15 mg/kg TXA prior to surgery, and the remaining 320 patients received no TXA. All the patients received a fast-track program including nutrition management, blood management, pain management, VTE prophylaxis and early mobilization and early intake. The primary outcome was transfusion requirement, other parameters such as blood loss, hemoglobin (Hb) level, VTE, adverse events and length of hospital stay were also compared. Multivariate logistic regression analysis and meta-analysis were also performed to identify the risk factors of transfusion and confirm the results of current study. Results. Transfusion of at least 1U of erythrocyte blood cell occurred in 25 patients (8.65%) in treatment group and in 77 (24.06%, OR=0.299, p<0.001) in control group. The mean level of Hb on POD 1 (111.70±18.40 g/L) and POD 3 (108.16±17.25 g/L) in TXA group were higher than control group (107.29±18.70 g/L, p= 0.008; 104.22±15.16 g/L, p= 0.005 respectively). More patients get off bed to ambulate within 24 hours after surgery in TXA group (37.02% Vs 26.25%, p= 0.004). And the length of hospital stay was shorter (11.82±4.39 Vs 15.96±7.30, p= 0.003). No statistical significance were detected regarding VTE and other adverse events. Logistic regression analysis showed that the relative odds reduction after adjustment for these covariates was 67% (OR= 0.327, 95%CIs= 0.197 to 0.544) in favor of tranexamic acid. Other risk factors included preoperative hemoglobin level, operation time, VTE prophylaxis. Pooling the data showed that tranexamic acid led to a significant reduction in transfusion (OR= 0.33, 95%CIs= 0.25 to 0.43) without sacrificing safety (OR= 0.70, 95%CIs= 0.25 to 1.97). Conclusion. Tranexamic acid was effective and safe to reduce blood loss and transfusion in geriatric hip fracture patients undergoing fast-track hemiarthroplasty

Introduction. The original Charnley-type negative pressure body exhaust suit reduced infection rates in randomized trials of total joint arthroplasty decades ago. Modern positive pressure surgical helmet systems (SHS) have not shown similar benefit, and several recent studies have shown a trend towards increased wound contamination and infection with SHS use. The gown glove interface may be one source of particle contamination. Objectives. The purpose of this study was to compare particle contamination at the gown glove interface in several modern SHS vs. a conventional gown. Methods. A 0.5 micron fluorescent powder was evenly applied to both hands to the level of the wrist flexion crease. After gowning in the normal fashion, the acting surgeon performed a standardized twenty minute simulated total joint replacement. The amount of gown contamination at the gown glove interface was then measured by three observers under ultraviolet light using a standardized grading scale; from 0 (no contamination) to 4 (gross contamination). Using Minitab 15, the Mann-Whitney U test was performed to compare gowns and an ordinal logistic regression analysis was performed to identify variables associated with levels of contamination. Results. All gown-glove interfaces showed some contamination. There was no difference among any of the gowns except for gown 2, which showed significantly more contamination when compared directly to each of the other four gowns (p<0.001 in each case) (Figure 1). The ordinal logistic regression analysis showed that gown type (p 0.10) was more significantly associated with contamination levels than were the other variables of observer (p 0.70), location of contamination (p 0.56), or trial order (p 0.5). Conclusions. Particle contamination occurs at the gown glove interface in most commonly used surgical helmet systems and was significantly increased in the gown with stiffer material that may be less apt to make a seal with the glove

Solitary fibrous tumor (SFT) is a rare mesenchymal tumor with an intermediate tendency to metastasize, which is found in many different locations including head and neck, abdomen, chest cavity and extremities. Also, meningeal hemangiopericytoma (HPC) is considered an SFT which arises in the meningeal membranes. SFT family shows an undetermined biologic behavior varying from a silent indolent tumor to an aggressive malignant form; however, benign and malignant variants of SFT may have similar cytopathologic characteristics. In this study, we defined the factors correlated with SFT's aggressive behavior and patient's survival. This is a retrospective study based on medical records of 85 patients who were suffering from SFT and had been treated at McGill University Health Centre (MUHC) between 1984 and 2017. We used multivariate logistic regression analysis to address any association between the variables including patient's demographics, tumor size, primary location of the tumor, pathological features, treatment methods and outcomes. The median of the follow-up period was 60 months. The patient's age or gender had no association with tumor aggressive behavior or patient's survival. Anatomical origin of primary tumor had no strong correlation with the patient's disease related death (DRD); however, tumors originated from CNS showed more aggressive behavior. There was an association between tumor size more than 7 cm and distant metastasis (MT) (p= 0.03) and DRD (p=0.03). The tumor size also correlated with the 5-year disease-free survival (p=0.017). We had three histologic groups: 1- Benign SFT (30 cases), 2- cellular SFT or HPC (29 cases), 3- malignant SFT or anaplastic HPC (26 cases). Although univariate analysis demonstrates that patients suffering from cellular SFT and malignant SFT showed increased aggressive behavior of the tumor, multivariate analysis didn't verify the mentioned association. Patients with positive margins had increased odds ratio to experience tumor local recurrence (LR) (p= 0.05) and LR was correlated with DRD in our patients (p=0.006). Radiotherapy had no statistical association with LR, MT or DRD. Frequency of LR and MT in the study were 25.7% and 29.8% respectively. 5-year disease-free survival in our patients was 76%. The size of SFT is the most correlative predictor of the tumor's aggressive behavior. The local recurrence of SFT is associated with disease related death; therefore, resection of the tumor with negative margins provides the highest chance of cure. In addition, a cellular SFT should be treated like a malignant variant of the tumor

Distal femoral physeal fractures can cause of growth distrurbance which frequently requires further surgical intervention. The aim of this study was to determine if tibial tuberosity ossification at the time of injury can predict further surgery in patients who have sustained a physeal fracture of the distal femur. We retrospectively investigated all patients who had operative treatment for a distal femoral physeal fracture at a paediatric level one trauma center over a 17 year period. Logistic regression analysis was performed investigating associations between the need for further surgery to treat growth disturbance and tibial tuberosity ossification, age, Salter Harris grade, mode of fixation or mechanism of injury. 74 patients met the inclusion criteria. There were 57 boys (77%) and 17 girls (23%). The average age at time of injury was 13.1 years (range 2.-17.1 years). Following fixation, 30 patients (41%) underwent further surgery to treat growth disturbance. Absence of tibial tuberosity fusion to the metaphysis was significantly associated with need for further surgery (p = < 0 .001). Odds of requiring secondary surgery after tibial tuberosity fusion to metaphysis posteriorly (compared with not fused) were 0.12, 95% CI (0.04, 0.34). The estimate of effect of tibial tuberosity ossification on reoperation rates did not vary when adjusted for gender, mechanism, fixation and Salter Harris grade. When accounting for age, the odds of further operation if the tibial tuberosity is fused to the metaphysis posteriorly (compared with not fused) were 0.28, 95% CI (0.08, 0.94). Tibial tuberosity ossification stage at time of injury is a predictor of further surgery to treat growth disturbance in paediatric distal femoral fractures. Children with distal femoral physeal fractures whose tibial tuberosity was not fused to the metaphysis posteriorly were 8.3 times more likely to require further surgery

Despite long-standing dogma, a clear relationship between the timing of surgical irrigation and the development of subsequent deep infection has not been established in the literature. Traditionally, irrigation of an open fracture has been recommended within six-hours of injury based on animal studies from the 1970s, however the clinical basis for this remains unclear. Using data from a multi-centre randomized controlled trial of 2,447 open fracture patients, the primary objective of this secondary analysis is to determine if a relationship exists between timing of wound irrigation (within six hours of injury versus beyond six hours) and subsequent reoperation rate for infection or healing complications within one year for patients with open extremity fractures requiring surgical treatment. To adjust for the influence of patient and injury characteristics on the timing of irrigation, a propensity score was developed from the data set. Propensity-adjusted regression allowed for a matched cohort analysis within the study population to determine if early irrigation put patients independently at risk for reoperation, while controlling for confounding factors. Results were reported as odds ratios (ORs), 95% Confidence Intervals (CIs), and p-values. All analyses were conducted using STATA 14 (StataCorp LP, College Station, TX, USA). Two thousand, two hundred eighty-six of 2,447 patients randomized to the trial from 41 orthopaedic trauma centers across five countries had complete data regarding time to irrigation. Prior to matching, the patients managed with early irrigation had a higher proportion requiring reoperation for infection or healing complications (17% versus 12.8%, p=0.02), however this does not account for selection bias of more severe injuries preferentially being treated earlier. After the propensity score-matching algorithm was applied, there were 373 matched pairs of patients available for comparison. In the matched cohort, reoperation rates did not differ between early and late groups (16.1% vs 16.6%, p=0.84). When accounting for propensity matching in a logistic regression analysis, early irrigation was not associated with reoperation (OR 0.93, 95% CI 0.62 to 1.40, p=0.73). When accounting for other variables, late irrigation does not independently increase risk of reoperation

Revision total knee arthroplasty (TKA) procedures performed secondary to periprosthetic joint infection (PJI) are associated with significant morbidity and mortality. These poor outcomes may be further complicated by the development of postoperative infection requiring aggressive antibiotic treatment. However, this antibiotic overuse may suppress patients' native bacterial flora, leading to Clostridium difficile infection (CDI). With the increased demand for primary TKAs and expected rise in revision TKA due to PJI, it is important to identify factors contributing to CDI. Therefore, we aimed to study the: 1) incidence, 2) demographics, length of stay (LOS), and total costs, and 3) risk factors and mortality associated with CDI in revision TKA patients. The National Inpatient Sample database was queried for all individuals diagnosed with PJI and who underwent revision TKA between 2009 and 2013. Patients who developed CDI during their in-patient hospital stay were identified, yielding 83,806 patients (799 with CDI) with a mean age of 65 (S.D.=11.2). Logistic regression analysis was conducted to assess the association between hospital- and patient-specific characteristics and the development of CDI. During the study period, the overall incidence of CDI after revision TKA was 1%. These patients were significantly older (mean age 69.05 vs. 65.52 yrs), had greater LOS (median 11 vs. 5 days), had greater costs ($30,612.93 vs. 18,873.75), and had higher in-hospital mortality (3.6 vs. 0.5%, p < 0 .001 for all) compared to those without infection. Patients with CDI were more likely to be treated in urban, not-for-profit, medium or large bed-sized hospitals located in the Northeast or Midwest (p < 0 .05 for all). Patients with underlying depression (OR 4.267, p=0.007) or fluid/electrolyte disorders (OR 3.48, p=0.001) were more likely to develop infection. Although CDI is a rare event following revision TKA, it can have detrimental consequences. Our report demonstrates that CDI is associated with longer LOS, higher costs, and greater in-hospital mortality. With increased legislative pressure to lower healthcare expenditures, it is crucial to identify means of preventing costly complications

Despite the widespread success of total hip arthroplasty (THA), postoperative pain management remains a concern. Opioids have classically been administered for pain relief after THA, but their side effect profile, in addition to the cognizance of the growing opioid epidemic, has incited a shift toward alternative pain modalities. Although the nonsteroidal anti-inflammatory drug (NSAID) diclofenac is a promising addition, its impact on immediate THA outcomes has not previously been investigated. Thus, in the present study, we evaluate the effects of adjunctive diclofenac on: 1) postoperative pain intensity, 2) opioid consumption, 3) discharge destination, 4) length of stay, and 5) patient satisfaction in primary THA patients. A retrospective review was performed to identify all patients who underwent primary THA by a single surgeon between May 1 and September 31, 2017. Patients were stratified into a study group (n=25), who were treated with postoperative diclofenac in addition to the standard pain control regimen, and a control group (n=88), who did not receive adjunctive diclofenac. Repeated-measures analysis of variance (ANOVA)/analysis of covariance (ANCOVA) and chi-square/logistic regression analysis were used for continuous and categorical variables, respectively. Patients receiving adjunctive diclofenac were more likely to be discharged home than to inpatient facilities (O.R. 4.02, p=0.049). In addition, patient satisfaction with respect to how well and how often pain was controlled (p= 0.0436 and p=0.0217, respectively) was significantly greater in the diclofenac group. Finally, patients who received diclofenac had lower opioid consumption on postoperative days one and two (−67.2 and −129 mg, respectively, p=0.001 for both). The rapid growth of THA as an outpatient procedure has intensified the urgency of improving postoperative pain management. The present study demonstrates that THA patients receiving adjunctive diclofenac were more likely to be discharged home, had reduced opioid consumption, and experienced greater satisfaction. This will, in turn, decrease complications and total hospital costs, leading to a more cost-effective pain control regimen. In order to further investigate the optimal regimen, future studies comprising larger cohort, as well as a comparison of diclofenac to other NSAIDs, are warranted

Avascular necrosis (AVN) of the femoral head is a potentially devastating complication of treatment for developmental dysplasia of the hip (DDH). AVN most commonly occurs following operative management by closed (CR) or open reduction (OR). This occurrence has frequently been examined in single centre, retrospective studies, however, little high-level evidence exists to provide insight on potential risk factors. The purpose of this observational, prospective multi-centre study was to identify predictors of AVN following operatively-managed DDH. A multi-centre, prospective database of infants diagnosed with DDH from 0–18 months was analyzed for patients treated by CR and/or OR. At minimum one year follow-up, the incidence of AVN (Salter criteria) was determined from AP pelvis radiographs via blinded assessment and consensus discussion between three senior paediatric orthopaedic surgeons. Patient demographics, clinical exam findings and radiographic data were assessed for potential predictors of AVN. A total of 139 hips in 125 patients (102 female, 23 male) underwent CR/OR at a median age of 10.4 months (range 0.7–27.9). AVN was identified in 37 cases (26.6% incidence) at a median 23 months post-surgery. Univariate logistic regression analysis comparing AVN and no AVN groups identified sex, age at diagnosis, age at surgery, pre-surgery IHDI grade and time between diagnosis and surgery as potential predictive factors. Specifically, male sex (OR 2.21 [0.87,5.72]), IHDI grade IV, and older age at diagnosis (7.4 vs. 9.5 months) and surgery (10.2 vs. 13.6 months) were associated with development of AVN. Likewise, increased time between diagnosis and surgery (2.9 vs. 5.5 months) was also associated with a higher incidence. No association was found with surgery type (CR vs. OR), pre-surgery acetabular index or surgical hip. Development of AVN occurred in 26.6% of hips undergoing CR or OR at a median 23 months post-surgery. Male sex, older age at diagnosis and surgery, dislocation severity and increased time between diagnosis and surgery were associated with AVN. Longer-term follow-up and larger numbers will be required to confirm these findings. Early outcomes from this prospective patient cohort suggest that AVN is an important complication of operative management for DDH, and appears to occur at a comparable rate whether the reduction is performed open or closed. Male patients may be more susceptible to developing AVN and merits further exploration. Potential predictive factors of older age and length of time between diagnosis and surgery emphasize the importance of early detection and treatment to minimize complications and optimize outcomes

Introduction. Acquiring adaptive soft-tissue balance is one of the most important factors in total knee arthroplasty (TKA). However, there have been few reports regarding to alteration of tolerability of varus/valgus stress between before and after TKA. In particular, there is no enough data about mid-flexion stability. Based on these backgrounds, it is hypothesized that alteration of varus/valgus tolerance may influence post-operative results in TKA. The purpose of this study is an investigation of in vivo kinematic analyses of tolerability of varus/valgus stress before and after TKA, comparing to clinical results. Materials and Methods. A hundred knees of 88 consecutive patients who had knees of osteoarthritis with varus deformity were investigated in this study. All TKAs (Triathlon, Stryker) were performed using computer assisted navigation system. The kinematic parameters of the soft-tissue balance, and amount of coronal relative movement between femur and tibia were obtained by interpreting kinematics, which display graphs throughout the range of motion (ROM) in the navigation system. Femoro-tibial alignments were recorded under the stress of varus and valgus before the procedure and after implantation of all components. In each ROM (0, 30, 60, 90, 120 degrees), the data of coronal relative movement between femur and tibia (tolerability) were analyzed before and after implantation. Furthermore, correlations between tolerability of varus/valgus and clinical improvement revealed by ROM and Knee society score (KSS) were analyzed by logistic regression analysis. Results. Evaluation of soft tissue balance with navigation system revealed that the tolerance of coronal relative movement between femur and tibia (varus/valgus) after implantation was significantly decreased compared with before implantation even in mid-flexion range. There were no significant correlations between tolerability of coronal relative movement and improvement of extension range and KSS. However, mid-flexion tolerability showed negative correlation with flexion range. Discussion. One of the most important principles for ligament balancing in TKA for varus knees is involved that the medial extension gap should be within 1–3mm to avoid flexion contracture and a feeling of instability, the medial flexion gap should be equal or 1–2mm larger to the medial extension gap, and lateral extension laxity up to 5 degrees is acceptable. However, there have been few reports measuring laxity from 30 to 60 degrees. In this study, the tolerance of coronal relative movement was significantly limited even in mid-flexion. However, mid-flexion tightness was not significantly correlated with clinical results except for flexion range. This result might be suggested that high tolerability of coronal relative movement in mid-flexion range may lead to widening of flexion range of motion of the knee after TKA. For any figures or tables, please contact authors directly

Regaining the walking ability is one of the main purposes of total knee arthroplasty (TKA). Improving the activities of daily living is a key of patient satisfaction after TKA. However, some patients do not gain enough improvement of ADL as they preoperatively expected, and thus are not satisfied with the surgery. The purpose of this study is to clarify the relationship between preoperative and postoperative physical functional status and whether preoperative scoring can predict the postoperative walking ability. Consecutive 136 patients who underwent total knee arthroplasty for osteoarthritis were prospectively assessed. The average age (±SD) was 74±7.7 and 74% of the patients was female. Berg Balance Scale (BBS) was assessed preoperatively and one year after the surgery. The time needed for 10m walking, muscle power for knee extension and flexion, visual analog scale (VAS) for pain in walking, and necessity of canes in walking were also assessed at one year after the surgery. Multivariate correlation analysis was performed for each parameter. Speaman rank correlation coefficient revealed that preoperative BBS was significantly correlated with the time needed for 10m walking (ρ=0.66, p<0.001). Logistic regression analysis also revealed that preoperative BBS is also correlated with the necessity for canes in walking one year after the surgery. The cut-off value of preoperative BBS for the necessity of canes in walking by ROC curve analysis was 48 points with 79% in sensitivity and 80% in specificity. The muscle powers were also weakly correlated with the walking ability at one year after the surgery, but VAS for pain was not. The study indicated that preoperative physical balance could predict the ability of walking one year after TKA regardless of the reduction of pain. It is suggested that surgery should be recommended before the physical balance function deteriorates to achieve the better walking ability after the TKA

Introduction. The global rapid growth of the aging population has some likelihood to create a serious crisis on health-care and economy at an unprecedented pace. To extend Healthy Life Expectancy (HALE) in a number of countries, it is desired more than ever to investigate characteristic and prognosis of numerous diseases. This enlightenment and recent studies on patient-reported outcome measures (PROMs) will drive the increasing interest in the quality of life among the world. The demand for primary THAs by 2030 would rise up to 174% in USA. It is expected that the number of the elderly will surge significantly in the future, thus more septuagenarian and octogenarian are undergoing THA. Moreover, HALE of Japanese female near the age of 75 years, followed to Singapore, is still increasing. Therefore, concerns exist about the PROMs of performing THA in this age-group worldwide. Nevertheless almost the well-established procedure, little agreement has been reached to the elderly. We aimed to clarify the mid-term PROMs after THA over 75-year old. Methods. Between 2005 and 2013, we performed 720 consecutive primary cemented THAs through a direct lateral approach. Of these, 503 female patients (655 hips) underwent THA for treatment of osteoarthritis, with a minimum follow-up of 5 years, were retrospectively enrolled into the study. We excluded 191 patients (252 hips) aged less than 65-year at the time of surgery and 58 patients (60) because of post-traumatic arthritis or previous surgery (37), or lack of data (23). Thus, 343 hips remained eligible for our study, contributed by 254 patients. We investigated Quality-adjusted life year (QALY), EuroQol 5-Dimension 5-Level scale (EQ-5D) and the Japanese Orthopaedic Association Hip-Disease Evaluation Questionnaire (JHEQ, which was a disease-specific and self-administered questionnaire, reflecting the specificity of the Japanese cultural lifestyle) in patients aged 75 years or older (154 hips, Group-E) compared with those aged 65 to 74 years (189 hips, Group-C) retrospectively. We evaluated the association between patients aged 75 years or older and the following potential risk factors, using logistic regression analysis: age, number of vertebral fractures (VFs), American Society of Anesthesiologists physical status (ASA-PS) and Charlson Comorbidity Index (CCI). A p value of < 0.05 was considered significant for the Mann-Whitney U test. Results. At a mean follow-up duration of 7.2 years, QALY, EQ-5D and JHEQ for the domain of patient satisfaction were significantly greater for Group-E than Group-C; however, there were no significant differences in JHEQ for pain, movement and mental-health between groups. On multivariate analysis, the age (odds ratio [OR] 2.48, p < .01 for EQ-5D; OR .32, p < .01 for JHEQ satisfaction), VFs (OR 1.63, p < .01 for satisfaction) and ASA-PS (OR .64, p = .31 for EQ-5D) were independent predictive risk factors for patients aged 75-year or older. Conclusions. Based on mid-term follow-up of PROMs study, we suggest that cemented THA can lead to the extension of HALE towards the super aged society and our results can be applied to a systematic analysis for the Global Burden of Disease Study related frailty

Aim. Data on Prosthetic joint infection (PJI) caused by multi-drug resistant (MDR) or XDR (extensively drug resistant) Gram negative bacteria (GNB) are limited. Treatment options are also restricted. We conducted a multi-national, multi-center assessment of clinical data and factors of outcome for these infections. Method. PJI were defined upon international guidelines. Data from 2000–2015 on demographics, clinical features, microbiology, surgical treatment and antimicrobial therapy was collected retrospectively. Factors associated with treatment success were evaluated by logistic regression analysis. Results. A total of 133 PJI were evaluated. Female (n=84, 61.4%) and the elderly [mean age (+/-SD) 73 (12.7)] predominated. Diabetes mellitus was the most frequent comorbidity (n=42,32.1%) followed by rheumatoid arthritis (n=14,10.7). Most PJI were early infections (84.4 %). XDR accounted for 23 cases; half of them due to Pseudomonas aeruginosa. Prevalence of MDR or XDR GNB was not different between early and late PJIs (p=0.114). Overall, P.aeruginosa (n=25, 19.1%) was followed by Klebsiella spp (n=23,17.6%) and Enterobacter spp (n=22,16.8%). PJI was located at the hip (n=85 65.6%), knee (n=41,31.3%), shoulder (n=3,2.3%) and ankle (n=1, 0.8%). Clinical characteristics included soft tissue infection (66.4%), pain (51.1%), fever (32.1%) and sinus tract(29.8%). Surgery for PJIs consisted of DAIR (debridement, antibiotics and implant retention), (n=64, 49.6%), followed by explantation of the arthroplasty (n=32, 24.8%), two-stage revision (n=16, 12,4%), one stage revision (n=9, 7%), arthrodesis (n=2, 1.6%). Median duration of antibiotic therapy was 51 days (IQR 25–75: 40–90 days). Cure after treatment was assessed in 78 patients (58.6%). No-DAIR surgical procedures in PJIs were more likely to be successful compared to DAIR surgery (75.8% vs 50%, OR 3.13, 95% CI:1.47–6.70, p=0.003)both in early or late infections. Conclusions. PJI by MDR/XDR GNB affects female, the elderly with comorbidities and previous surgery for PJI. P.aeruginosa is frequent, mostly XRD. No-DAIR procedures have higher probability of treatment success than DAIR even in early infection. Despite surgery and long-term antimicrobial administration, treatment success was less than 60%, probably reflecting the lack of effective treatment options