Aims. The aim of this study was to investigate mortality and risk of intraoperative medical complications depending on delay to hip fracture surgery by using data from the Norwegian Hip Fracture Register (NHFR) and the Norwegian Patient Registry (NPR). Patients and Methods. A total of 83 727 hip fractures were reported to the NHFR between 2008 and 2017. Pathological fractures, unspecified type of fractures or treatment, patients less than 50 years of age, unknown delay to surgery, and delays to surgery of greater than four days were excluded. We studied total delay (fracture to surgery, n = 38 754) and hospital delay (admission to surgery, n = 73 557). Cox regression analyses were performed to calculate relative risks (RRs) adjusted for sex, age, American Society of Anesthesiologists (ASA) classification, type of surgery, and type of fracture. Odds ratio (OR) was calculated for intraoperative medical complications. We compared delays of 12 hours or less, 13 to 24 hours, 25 to 36 hours, 37 to 48 hours, and more than 48 hours. Results. Mortality remained unchanged when total delay was less than 48 hours. Total delay exceeding 48 hours was associated with increased three-day mortality (RR 1.69, 95% confidence interval (CI) 1.23 to 2.34; p = 0.001) and one-year mortality (RR 1.06, 95% CI 1.04 to 1.22; p = 0.003). More intraoperative medical complications were reported when hospital delay exceeded 24 hours. Conclusion. Hospitals should operate on patients within 48 hours after fracture to reduce mortality and intraoperative complications. Cite this article: Bone Joint J 2019;101-B:1129–1137

Our aim was to determine the effect of delay to surgery on the time to discharge, in-hospital death, the presence of major and minor medical complications and the incidence of pressure sores in patients with a fracture of the hip. All patients admitted to Vancouver General Hospital with this injury between 1998 and 2001 inclusive were identified from our trauma registry. A review of the case notes was performed to determine the delay in time from admission to surgery, age, gender, type of fracture and medical comorbidities. A time-to-event analysis was performed for length of stay. Additionally, a Cox proportional hazards model was used to determine the effect of delay to surgery on the length of stay while controlling for other pertinent confounding factors. Using logistical regression we determined the effect of delay to surgery on in-hospital death, medical complications and the presence of pressure sores, while controlling for confounding factors. Delay to surgery (p = 0.0255), comorbidity (p < 0.0001), age (p < 0.0001) and type of fracture (p = 0.0004) were all significant in the Cox proportional hazards model for increased time to discharge. Delay to surgery was not a significant predictor of in-hospital mortality. However, a delay of more than 24 hours was a significant predictor of a minor medical complication (odds ratio (OR) 1.53, 95% confidence interval (CI) 1.05 to 2.22), while a delay of more than 48 hours was associated with an increased risk of a major medical complication (OR 2.21, 95% CI 1.01 to 4.34), a minor medical complication (OR 2.27, 95% CI 1.38 to 3.72) and of pressure sores (OR 2.29, 95% CI 1.19 to 4.40). Patients with a fracture of the hip should have surgery early to lessen the time to acute-care hospital discharge and to minimise the risk of complications

The surgical treatment of unicompartmental knee osteoarthritis remains controversial. This study aims to compare the medium-term outcomes of age and gender matched patients treated with unicompartmental knee replacement (UKR) and total knee replacement (TKR). We retrospectively reviewed pain, function and total knee society scores (KSS) for every UKR and age and gender matched TKR in NHS Tayside, with up to 10 years prospective data from Tayside Arthroplasty Audit Group. KSS was compared at 1, 3 and 5 years. Medical complications and joint revision were identified. Kaplan-Meier with revision as end-point was used for implants survival analysis. 602 UKRs were implanted between 2001 and 2013. Preoperative KSS for pain and total scores were not significantly different between UKRs and TKRs whereas preoperative function score was significantly better for UKRs. Function scores remained significantly better in UKRs from preoperative until 3 years follow up. Further analysis revealed no statistically significant difference in the change of function scores in both groups over time. There was a trend for TKRs to perform better than UKRs in pain scores. Total KSS for both groups were not significantly different at any point of the 5-year study. Fewer medical complications were reported in the UKR group. Kaplan-Meier analysis showed a survival rate of 93.7% in UKRs and of 97% in TKRs (Log rank p-value = 0.012). The revision rate for UKR was twice as much as TKR. The theoretical advantages of UKR are not borne out by the findings in this study other than immediate postoperative complications

Aims. To compare the outcomes for trochanteric fractures treated with a sliding hip screw (SHS) or a cephalomedullary nail. Patients and Methods. A total of 400 patients with a trochanteric hip fracture were randomised to receive a SHS or a cephalomedullary nail (Targon PFT). All surviving patients were followed up to one year from injury. Functional outcome was assessed by a research nurse blinded to the implant used. Results. Recovery of mobility, as assessed by a mobility scale, was superior for those treated with the intramedullary nail compared with the SHS at eight weeks, three and nine months (p-values between 0.01 and 0.04), the difference at six and 12 months was not statistically significant (p = 0.15 and p = 0.18 respectively). The mean difference was around 0.4 points (0.3 to 0.5) on a nine point scale. Surgical time for the nail was four minutes less than that for the SHS (p < 0.001). Fracture healing complications were similar for the two groups. There were no statistically significant differences between implants for any other recorded outcomes including the need for post-operative blood transfusion, wound healing complications, general medical complications, hospital stay or mortality. Conclusion. This study confirms the findings of a previous study that both methods of treatment produce similar results, although intramedullary fixation does result in marginally improved regain of mobility in comparison with the SHS. Cite this article: Bone Joint J 2017;99-B:1210–15

Aims

Despite limited clinical scientific backing, an additional trochanteric stabilizing plate (TSP) has been advocated when treating unstable trochanteric fractures with a sliding hip screw (SHS). We aimed to explore whether the TSP would result in less post operative fracture motion, compared to SHS alone.

Aims

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

Ankle fractures are common injuries and the third most common fragility fracture. In all, 40% of ankle fractures in the frail are open and represent a complex clinical scenario, with morbidity and mortality rates similar to hip fracture patients. They have a higher risk of complications, such as wound infections, malunion, hospital-acquired infections, pressure sores, veno-thromboembolic events, and significant sarcopaenia from prolonged bed rest.

Aims

Tobacco, in addition to being one of the greatest public health threats facing our world, is believed to have deleterious effects on bone metabolism and especially on bone healing. It has been described in the literature that patients who smoke are approximately twice as likely to develop a nonunion following a non-specific bone fracture. For clavicle fractures, this risk is unclear, as is the impact that such a complication might have on the initial management of these fractures.

Aim. Circular frames are used to treat a wide spectrum of acute injuries and deformities. We report on our experience of treating both acute and chronic trimalleolar fracture dislocations with a closed technique, utilizing fine wires and a circular frame. Methods. Data was collected from all patients treated for either acute or chronic trimalleolar fracture dislocations at a single centre between January 2016 and December 2017. A total of 10 patients were identified, 8 with acute injuries and 2 with chronic/delayed injuries. Clinical and radiological outcomes were recorded, as well as patient reported outcome measures (PROMs) using the Chertsey Outcome Score for Trauma (COST score). Results. 8 patients were treated for acute trimalleolar fractures, 2 of which were open medially. One patient had sustained a further break and metalwork failure following fixation for trimalleolar fracture at another hospital and 1 patient presented 6 weeks post injury. Average age was 53.6 years (range 20–86). Average time to surgery following acute injury was 4.3 days (0–12). Average follow up to date was 25 weeks (2–60). All patients had satisfactory alignment and union at completion of treatment. The average COST score (n=8) was 52/100 (30–90). 3 patients had pin site infections managed with antibiotics. One patient died due to unrelated medical complications. Conclusion. Initial use of circular frames for trimalleolar fracture has shown excellent results in terms of radiological, clinical and patient reported outcome measures. Complications have been limited to date

Introduction. Femoral neck fractures are an increasingly common injury in the elderly. Frequently these patients present taking Clopidogrel, an irreversible inhibitor of platelet aggregation. Although this is associated with an increased risk of intra-operative bleeding and also an increased risk of spinal haematoma where regional anaesthesia is employed, the recent SIGN (Scottish Intercollegiate Guidance Network) guidelines recommend that surgery should not be delayed. Methods. We conducted a retrospective review of consecutive patients admitted with femoral neck fractures between April 2008 and October 2009. Patients on Clopidogrel were identified and data including ASA grade, time to operation, medical co-morbidities, and post-admission complications were recorded. Comparative information from the National Hip Fracture Database was used. Results. 405 patients were included. 27 patients were taking Clopidogrel on admission and they were mainly ASA 3 or 4. Mean time to theatre was 8 days. Post-admission medical complications occurred in 7 patients (25.9%). A further 4 patients (14.8%) died, 3 of them postoperatively. From the study population a control group of 72 ASA 3 and 4 patients was further studied. The mean time to operation was 2.3 days. Post-admission medical complications occurred in 13 patients (18%) and 8 patients (11%) died postoperatively. In 2009 the national mean time to operation was 2.19 days with an associated mortality rate of 8.67%. Discussion and Conclusion. Patients receiving Clopidogrel have complex medical co-morbidities and a higher anaesthetic risk. Delaying operative management might be contributing to the increased rate of mortality and morbidity. In accordance with the SIGN guidelines we recommend early operative intervention in these high risk patients

Aims

To evaluate if, for orthopaedic trainees, additional cadaveric simulation training or standard training alone yields superior radiological and clinical outcomes in patients undergoing dynamic hip screw (DHS) fixation or hemiarthroplasty for hip fracture.

Background. Medical complications and death are rare events following elective orthopaedic surgery. Diagnostic and operative codes are routinely collected on every patient admitted to hospital in the English NHS (hospital episode statistics, HES). This is the first study investigating rates of these events following total joint replacement (TJR) on a national scale in the NHS. Methods. All patients (585177 patients) who underwent TJR (hip arthroplasty [THR], knee arthroplasty [TKR], or hip resurfacing) between January 2005 and February 2010 in the English NHS were identified. Patients were subdivided based on Charlson co-morbidity score. HES data in the form of OPCS and ICD-10 codes were used to establish 30-day medical complication rates from myocardial infarction (MI), cerebrovascular event (CVA), chest infection (LRTI), renal failure (RF), pulmonary embolus (PE) and inpatient 90-day mortality (MR). Results. The overall 90-day MR after THR was 0.44% (1116 of 256013 patients), after hip resurfacing 0.06% (17 in 27314), and after TKR 0.34% (1023 of 301850). MI rate was 0.39% (2257 of 585177). Of these 15.8% (356) died. CVA rate was 0.01% (53). Of these 32.1% (17) died. LRTI rate was 0.60% (3389). Of these 12.1% (410) died. RF rate was 0.35% (2066). Of these 13.9% (287) died. PE rate was 0.71% (4144). Of these 3.9% (161) died. For patients with no co-morbidities, no personal history of PE or DVT, and no post-operative complications (70.8% of all patients in this study, 414061 of 585177), MR was 0.09% (394 patients). Discussion. This national data analysis allows a greater understanding of mortality risk following post-operative complications, and provides robust information for the consenting process. It also shows that the risk of mortality for fit patients without post-operative complications was very low - a group which is thought to have a high rate of ‘silent’ fatal PEs

Aims

The aim of this study was to describe the management and associated outcomes of patients sustaining a femoral hip periprosthetic fracture (PPF) in the UK population.

Introduction. Orthopaedic surgeons are frequently asked to perform a revision total hip arthroplasty (THA) in patients over 80 years of age. Our objective was to evaluate the outcomes after revision THA in patients 80 years or older and compare them to a cohort of patients less than 80 years of age. Methods. We reviewed all revision THAs performed in our institution from 3/1996 to 12/2008. We compared intra- and post-operative complications (medical and orthopaedic), mortality, clinical outcomes and patient satisfaction between the two age groups. Peri-operative information and complications were collected prospectively, and clinical outcome data were obtained both pro- and retrospectively. The Merle d'Aubigné score, Harris Hip score, general health (SF-12) and patient satisfaction (visual analog scale) were assessed. Results. Overall, 325 revision THAs were included, 84 (25.8%) in patients 80 years and 241 in patients <80 years. In both groups the reason for revision was aseptic loosening in 62% of the patients (mean interval primary THA - revision 142 vs. 97 months). The older group was more often revised for periprosthetic fractures and recurrent dislocation. Mean follow-up time was 4.3 years. Mortality (80 vs. <80 years) was 6% vs. 0% 3 months postoperative, 9.5% vs. 1.2% 1 year postoperative, and 31% vs. 8.3% 5 years postoperative. 3 (3.6%) re-revisions were performed in patients 80 years compared to 24 (10%) in the younger group. Postoperative medical complications developed in 22.6% compared to 6.6% in the younger group. There were one infection and 13 dislocations in patients 80 years vs. 12 infections and 22 dislocations in the other group. The Merle d'Aubigné score improved from 9.6 to 13.7 (p=0.001) in patients 80 years or older vs. 10.3 to 14.3 (p<0.001), and the Harris Hip score at last follow-up was 74.2 vs. 78.5. Patient satisfaction was significantly higher in the older group (8.4 vs. 7.5, mean difference 0.9, 95% CI 0.2;1.8). Conclusion. Revision THA in patients over 80 years was associated with substantial clinical improvement, and patient satisfaction was greater than among the younger group. However, the medical complication rate and the 3-months-mortality were substantially higher

Aims

The aim of this study was to investigate the rate of revision for distal femoral arthroplasty (DFA) performed as a primary procedure for native knee fractures using data from the Australian Orthopaedic Association National Joint Arthroplasty Registry (AOANJRR).

Our aim was to determine the total blood loss associated with surgery for fracture of the hip and to identify risk factors for increased blood loss. We prospectively studied 546 patients with hip fracture. The total blood loss was calculated on the basis of the haemoglobin difference, the number of transfusions and the estimated blood volume. The hidden blood loss, in excess of that observed during surgery, varied from 547 ml (screws/ pins) to 1473 ml (intramedullary hip nail and screw) and was significantly associated with medical complications and increased hospital stay. The type of surgery, treatment with aspirin, intra-operative hypotension and gastro-intestinal bleeding or ulceration were all independent predictors of blood loss. We conclude that total blood loss after surgery for hip fracture is much greater than that observed intra-operatively. Frequent post-operative measurements of haemoglobin are necessary to avoid anaemia

We undertook a prospective randomised controlled trial involving 400 patients with a displaced intracapsular fracture of the hip to determine whether there was any difference in outcome between treatment with a cemented Thompson hemiarthroplasty and an uncemented Austin-Moore prosthesis. The surviving patients were followed up for between two and five years by a nurse blinded to the type of prosthesis used. The mean age of the patients was 83 years (61 to 104) and 308 (77%) were women. The degree of residual pain was less in those treated with a cemented prosthesis (p < 0.0001) three months after surgery. Regaining mobility was better in those treated with a cemented implant (p = 0.005) at six months after operation. No statistically significant difference was found between the two groups with regard to mortality, implant-related complications, re-operations or post-operative medical complications. The use of a cemented Thompson hemiarthroplasty resulted in less pain and less deterioration in mobility than an uncemented Austin-Moore prosthesis with no increase in complications

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

Introduction. The purpose of this study was to compare the clinical outcomes and complications following bilateral simultaneous total knee arthroplasty in high body mass index (BMI) patients(>30kg/m. 2. ) to those of patients with a BMI<30 kg/m. 2. . Materials and Methods. Using data from an academic arthroplasty database and review of clinic charts we obtained health related quality of life (SF-12), and disease specific functional outcome scores (WOMAC or Oxford Knee Score). We also assessed length of hospital stay, ASA grade and transfusion requirements. Sixty six patients had a BMI<30 and 151 patients had a BMI>30. Results. Most cases were performed under combined spinal/epidural anaesthesia. We could find no appreciable difference in length of hospital stay, ASA grade or transfusion requirements between the two subgroups. Furthermore, were unable to detect any significant differences in post operative SF-12, WOMAC or Oxford Knee scores. There appeared to be no significant increase in the rate of medical complications between the two subgroups, and while there may have been a slight trend towards higher procedure related complications in the high BMI group, this did not reach statistical significance. Conclusions. In our study increased BMI appears to have no negative effects as regards functional outcomes, hospital stay or transfusion requirements for bilateral sequential knee arthroplasty. However there may be an increase in procedural/device related complications which could result in increased revision rates in these patients

Proximal femoral fractures remain the most common reason for admission to hospital following orthopaedic injury, with an annual cost of £1.7 billion to the National Health Service and social care services. Fragility fractures of the hip in the elderly are a substantial cause of mortality and morbidity. Revision surgery for any cause carries a higher morbidity, mortality, healthcare- and social economic burden. Which patients suffer failed surgery and the reasons for failure have not been established. The aim of this study was to determine which patients are at risk of failed proximal femoral fracture surgery, the mechanism and cause fo failed surgery and modifiable patient factors associated with failure of hip fracture surgery. From prospectively collected data of 795 consecutive proximal femoral fractures admitted between July 2007 and July 2008, all peri-operative and post-operative complications were identified. 55 (6.9%) patients were found to have developed a surgical complication requiring further intervention. Risk factors included younger age (p=0.01), smoking (p=0.01) and cannulated screw fixation (p<0.01). Cannulated screw fixation was associated with a 30.9% complication rate. Mechanical cause was the most common reason for cannulated screw failure. Hip hemiarthroplasty most commonly failed by infective causes. Inter-trochanteric and subtrochanteric fracture fixation had very low failure rates. Surgical complication was not found to be associated with an increased mortality but a post-operative medical complication (21.8%) was associated with higher rate of mortality at 4-years (78.5%) and shorter time to mortality. (Median time 0.16 years (95% CI 0.00–0.33)