Complications are an inevitable part of orthopaedic surgery, how one defines complications can have an impact on the ability to learn from them. A group of general surgeons headed by Clavien and Dindo et al.1 have previously published their classification system for surgical complications based on the type of therapy required to correct the complication. Our aim was to evaluate a modification of this classification system and its use over a 12-month period at our institution via our departmental audits, our hypothesis being that this would direct appropriate discussion around our complications and hence learning and institutional change. A modified Clavien-Dindo Classification was prospectively applied to all complications recorded in the Orthopaedic departmental quarterly audits at our institution for a 12-month period (4 audits). The audit discussion was recorded and analysed and compared with the quarterly complication audits for the preceding 12-month period. The modified Clavien-Dindo classification for surgical complications was applicable and reproducible to Orthopaedic complications in our level 1 trauma centre. It is a transparent system, objective in its interpretation and avoids the tendency to down-grade serious complications. It was easy to apply and directed discussion appropriately at our quarterly audit meetings on complications where there was a preventable outcome or important learning point. In particular modifications to VTE and Death classes allowed the unit to focus discussion on cases where complication was preventable or unexpected. The modified Clavien-Dindo classification system is an easy to use and reproducible classification system for Orthopaedic complications in our unit it directed audit discussion towards cases where complications were preventable or had a learning point

Over the last decade, the number of total knee arthroplasty (TKA) has risen over 125%. Numerous studies have established a relationship between obesity and complications in primary TKA. Interestingly, few studies have investigated medical and orthopaedic complications in obese patients undergoing revision TKA (RTKA). With the increasing number of RTKA and with the prevalence of obesity still on the rise, the study of obesity on complications following RTKA is indicated. We retrospectively reviewed 180 RTKA performed by a single surgeon done between August 2008 and June 2017. All patients who underwent RTKA were included, but revisions done with simultaneous extensor mechanism reconstruction and/or distal femur replacement were excluded since these procedures are technically more demanding. 154 revisions met our inclusion/exclusion criteriaes and were included in the final analysis. 81 patients were included in the non-obese group (BMI . The total number of orthopaedic complications in the obese group (46.6%) was significantly higher than in the non-obese group (27.2%) (OR=1.71) (p = 0.01). The number of infection was higher in the obese group (11%) than in the non-obese (6.2%) but this was not statistically significant (OR=1.77) (p = 0.28). Reoperation rate was also higher in the obese group (23.3%) than in the non-obese group (16%) but this did not reach statistical significance (OR=1.46) (p = 0.26) (Table 3). Medical complications were higher in the obese group (31.5% vs 19.8%) (OR=1.59) (p=0.09). According to the Dindo-Clavien classification, the obese group demonstrated a significantly higher rate of grade 3 or higher complications (p = 0.01). Obesity significantly increases the occurrence of orthopaedic complications following RTKA. Obesity also seems to increase the number of medical complications following RTKA. The obese patient should be informed prior to revision TKA that there is an increased risk of complications when compared with the non-obese patient. Further research with higher power would seem advisable to confirm this trend. For any figures or tables, please contact the authors directly

Staphylococcus aureus osteo-articular infections (OAI) are frequently accompanied by blood stream infections (BSI) diagnosed by positive blood culture (BC). Microbiological protocols in adults advise prolonged intravenous antibiotics and repeat BC 48-hourly in the presence of a BSI, however evidence to support the systematic employment of these guidelines in paediatric patients is lacking. We aimed to determine whether there was an increased incidence of orthopaedic and systemic complications in patients with s aureus BSI, and whether a shorter duration of intravenous antibiotics was associated with the development of complications. Following ethical approval, the departmental surgical database was searched for patients that underwent surgery for acute OAI over a 5-year period. Patients with no sample taken for BC were excluded, as were those with other or no organisms identified from any site. Demographic and clinical data were captured, including duration of IV antibiotics and development of complications. Statistical significance was set at p<0.05. Following exclusions, 44 patients with a median age of 85 months remained to be analysed. Thirty patients (68%) had a positive BC. A positive BC was associated with a higher rate of systemic complications (p=0.026) but not orthopaedic complications (p=0.159). Patients who had developed any complication had a significantly longer duration of IV antibiotic treatment compared to those without complications (p<0.001). The presenting CRP levels were significantly higher in patients that developed complications (p=0.004). Patients with staphylococcal BSI in association with an OAI are at increased risk of developing systemic complications. In our cohort, a shorter duration of antibiotic use was not associated with the development of complications, which does not support the systematic use of long courses of IV antibiotics in s aureus BSI. Further research will be required to determine the ideal protocol for these patients

The recruitment drive, investment and collaboration within Betsi Cadwaladr University Health Board (BCUHB) sites providing specialist lower limb arthroplasty and trauma service has evolved over last few years with aims to improve patient care and reduce reliance on tertiary referral centres. Through our service-evaluation project, we reviewed the results of treatment provided for periprosthetic femur fractures (PPFFs) presenting to BCUHB sites over last 4 years. We retrospectively reviewed consecutive PPFFs admitted at three BCUHB sites from January’20 to June’23 with mean follow-up of 20.8 ± 13.2 (8–49) months [n=161; Mean age: 82.2 ± 8.5 (59–101) years, Females:107]. Over the review period we noted a 23% increase in service demand for care of PPFFs. Majority were managed surgically [132/161] [38 revision arthroplasties; 94 ORIFs] at BCUHB sites and two patients were referred to tertiary centre. Average time to surgery was 3.5 days. 90% of the PPFFs were managed successfully with 10% (16/159) having orthopaedic complications needing further intervention. 6.3 (10/159) had medical complications and did not need orthopaedic re-intervention. In our series, 12-month re-operation rate was 6.1% (8/132) and 1-month, 3-month and 1-year mortality rate was 6.3%, 11.3% and 21.4% respectively. These results are comparable to the published results of PPFF management at tertiary centres. Potential cost savings compared to transfer to tertiary centre for PPFF management was £2.31 million. Thus, it is possible to successfully provide adequate care for PPFFs at DGHs and efforts should be made to appropriately equip and adequately staff DGHs, to provide service for local PPFF care

The aim of this study is to use a defined population of patients with meningococcal septicaemia to calculate the incidence of orthopaedic complications. Medical records and radiographs were analyzed retrospectively for all patients admitted to the Paediatric Intensive Care Unit (PICU) of the Bristol Royal Hospital for Children from 01/01/2001 to 31/12/2012 with meningococcal septicaemia. Of the 130 patients with meningococcal septicaemia alive at discharge, 10 developed orthopaedic sequelae, representing an overall incidence in this patient population of 7.7%. 9 patients required an amputation, mostly in the lower limb, 16/22 (72.7%). 48 growth plate abnormalities were identified in 8 patients. 39 (81.3%) The most commonly affected was the distal tibia (38.5%). 10 ankles were identified as having a varus malalignment. 6 patients had documented leg length discrepancy. Using a clearly defined denominator this study has identified an incidence of orthopaedic sequelae following meningococcal septicaemia of 7.7%. The National Institute for Clinical Excellence (NICE) suggested that the incidence of growth disturbance is approximately 3%. This study highlights the underestimation of orthopaedic complications following meningococcal septicaemia. Close follow up of at risk patients should be considered to reduce the potential impact of these debilitating injuries

Meningococcal infection is the most common infective cause of death in children and causes significant morbidity in survivors. Patients admitted to the Paediatric Intensive Care Unit (PICU) of the Bristol Royal Hospital for Children from 01/01/2001 to 31/12/2012 with a primary diagnosis of meningococcal septicaemia were reviewed. A total of 10 (7.7%) of 130 patients developed orthopaedic complications. Those affected were significantly younger (p < 0.05), remained on PICU for longer (p < 0.001) and boys had a greater risk of developing orthopaedic complications (risk ratio: 3.1; 95% CI: 0.69–14.14). 9 patients required an amputation, 16/22 (72.7%) in the lower limb. Patient requiring amputation had multiple limb involvement. 48 growth plate abnormalities were identified in 8 patients, 39 (81.3%) in the lower limb, most commonly in the distal tibia. This study has identified a high incidence of musculoskeletal morbidity. Close surveillance of these patients is recommended to identify growth arrest before the onset of clinically significant deformity. It identifies a defined population of patients with meningococcal septicaemia using admission to PICU as an entry criterion allowing accurate determination of the incidence and characteristics of the skeletal consequences of this condition

Introduction. Correction of multiplanar bone deformities in children is indicated for prevention of secondary orthopaedic complications. Different problems related to surgical intervention were reported: non-union, delayed union, recurrent deformity, refracture, nerve palsy and pin tract infection. The aim of this study was to show the results of children femur and tibia bowing deformities by Ilizarov technique. Materials and Methods. We analysed 27 cases of children femur and tibia bowing deformities under the age of 13 yrs. Simultaneous deformity correction in femur and tibia was done with Ilizarov device in ipsilateral side. Contralateral side was operated after 14 days. Results. The duration of Ilizarov fixation was 130 days on an average. The deformity correction was achieved with a proper alignment in all the cases. Conclusions. Bowing of femur and tibia can be corrected simultaneously by Ilizarov fixation with minimum complications. There were no recurrent deformities in our cases

Osteomyelitis and septic arthritis are common pathologies in young children. Because of their skeletal immaturity, children are particularly vulnerable to orthopaedic complications, including limb-length discrepancies, angular deformities, chondrolysis, etc. The primary objective of this study was to review the clinical follow up and outcomes of paediatric patients diagnosed with osteoarticular infections. The secondary purpose was to look for significant differences in the clinical characteristics between the one with and without complications. Patients' medical charts, hospitalised between 2010 and 2016, were retrospectively reviewed. The inclusion criteria were: patients (1) aged of less than 10 years old (2) treated and followed for osteomyelitis of long bones of upper and lower extremities and/or septic arthritis (3) with at least one year of radiological follow up. The exclusion criterion was: (1) any concomitant chronic diseases. The information collected included demographic and clinical data. A late sequela was defined as a limb-length discrepancy superior to 5 mm or an abnormal articular angulation of more than 5°, or a symptomatic chondropathy. Patients were separated in two groups: with and without complications. Chi-square tests were used for categorical variables and Mann-Whitney U tests for continuous data in order to establish significant differences between both groups. Of the 401 patients with osteomyelitis and/or septic arthritis treated in our tertiary paediatric hospital over 7 years, 50 met the inclusion criteria. There were 24 girls and 26 boys. The etiological agent was identified in 56% of the cases. Staphylococcus aureus was the predominant causal pathogen (50%), followed by Kingella kingae (19.2%). The mean follow up was 780 days. Six out of 50 (12%) patients had physeal or chondrolytic complications at the latest follow-up. The only significant difference between the 2 groups was the delay between onset of symptoms and initiation of antibiotic therapy (P = 0.039). Only 12.5% of the patients were followed up at least one year. In the population of 50 skeletally immature patients without comorbidities, 12% had a sequela. The delay in initiating antibiotic treatment was significantly longer in the group with the presence of sequelae. The results of this study reveal that there were low rates of outpatient follow-up reaching more than a year after an osteoarticular infection, thus raising the question about the importance of a follow up after such a diagnosis. Twelve percent of the patients had a growth or chondrolysis complication and this might be related to the delay before initiating antibiotic treatment

Aims. To describe four South African patients (including a sibling pair) with pycnodysostosis and to highlight the importance of a comprehensive assessment of the patient, and not just the fracture. To emphasise the significance of the input of a multidisciplinary team which should include a medical geneticist, in order to provide optimal care for patients and their families. Methods. A comprehensive evaluation of the clinical and radiological features of these four patients was undertaken and the orthopaedic complications documented, with the times from presentation to definitive diagnosis. Results. All four patients presented to orthopaedic trauma departments several times for management of long bone fractures before a diagnosis of pycnodysostosis was suspected. Indeed the siblings were misdiagnosed as a different condition altogether. Delays in diagnosis meant that associated complications were not recognised timeously and patients were not referred to the relevant experts for specialist care. The younger of the siblings described died due to severe upper airway obstruction- a recognised, treatable and potentially preventable complication of the condition. Conclusion. Although patients present with fractures, it is imperative to look beyond the fracture. Obtaining a comprehensive medical and family history, along with a complete physical and radiological examination of any patient presenting with recurrent fractures or fractures sustained after minor injury, is important. An evaluation by a medical geneticist is invaluable in making the diagnosis and providing genetic counselling to the families. NO DISCLOSURES

Femoral neck fractures are the second cause of hospitalization in elderly patients. Nowadays it is still not clear whether surgical treatment may provide better clinical outcome than conservative treatment in patients affected by mental disorders, such as senile dementia. The aim of this study was to retrospectively assess mortality and clinical and functional outcome after hemi arthroplasty operation following intracapsular neck fractures in patients with senile dementia. Between 2008 and 2014, 819 patients were treated at our Orthopaedic Institute for neck fracture of the femur (mean age: 83.8 years old). Eighty-four of these showed clear signs of cognitive impairment at time of admission in the Emergency Department. Mental state of patients was assessed in all cases, as routine, at the Emergency Room with the Short Portable Mental Status Questionnaire (Sh-MMT) and the Mini Mental State Examination (MMSE). Patients were divided in two groups depending whether they were surgically treated with hemiarthroplasty (Group B, 46 patients; 35 females, 11 males; mean age: 88.5 y.o.) or conservatively treated (Group C, 38 patients; 28 females, 10 males; mean age: 79.5 y.o.). These two groups were compared with a matched case-control group of patients surgically treated with no mental disorders (Group A, 40 patients; 34 females, 6 males; mean age: 81.5 y.o.). Incidence of mortality, systemic or local complications and functional clinical outcomes were evaluated with the ADL score and the Barthel index. Mortality rate was 35% (14 patients) for Group A, 50% (21 patients) for Group B and 95% (22 patients) for Group C. Paired t-test, with significance rate set at 0.05, showed significant higher mortality rate in Group A compared to both Group B (p:0.02) and Group C (p:0.001), and also between Group B and Group C (p:0.01). Three orthopaedic complications were found in Group B (two cases of infection and one dislocation of the prosthesis) while none in Group A (p<0.001). There have been 14 overall general complication in Group A (33%), 16 in group B (38%) and 15 in Group C (65%), with significant higher rate in Group B vs. Group A (p:0.02) and in group C vs. Group B (p: 0.001). Activity daily living scale and Barthel Index results showed higher results in Group B than Group C both in terms of recovery of walking ability and daily living (hairdressing, wearing clothes, eating). For any figures or tables, please contact authors directly (see Info & Metrics tab above).

Introduction. Dislocation is one of the most common orthopaedic complications after primary total hip replacement (THR). The reported dislocation rate in elective THR is 5–8%. This number increases up to 22% for THR done for neck of femur fractures. Due to the reported increase in dislocation for trauma, some surgeons prefer to do a hemi-arthroplasty or open reduction and internal fixation (ORIF). Hemi-arthroplasty is known to have poorer functional outcomes. Failure of ORIF is as high as 43%, and revision of failed ORIF to THR has reported dislocation rates of up to 42%. Materials and methods. A retrospective review of all THR done for neck of femur fractures during 2006–2011 was undertaken. The patients in our institution who are considered for a THR must have an active life-style. Records were reviewed for delay to surgery, surgical approaches, articulations, bearing surfaces, follow up periods and cemented versus uncemented implants. We excluded all pathological fractures, extra-capsular fractures, failed ORIF, patients with incomplete data and patients with a follow-up period less than 3 months. Hip dislocation was the end-point of the review and we did not study other causes of revision e.g. loosening of components or infection. Results. A total of 115 cases were identified as suitable for analysis. Average age at surgery was 73.2 years (range 30–81). Delay to surgery was 5.3 days (range 1–63). Average follow up period was 18.3 months (range 3 months-4,3years). Four patients (3.4%) had a confirmed dislocation. Three of these patients had successful closed reduction and one patient required revision surgery and change of component orientation. Conclusion. Our early dislocation rate of 3.4% is within the published results and shows that primary THR is an acceptable and safe option for displaced intracapsular NOF in active patients. Most recent studies have shown superior functional outcomes of THR compared to hemi-arthroplasty or poorly performed ORIF. NO DISCLOSURES

Background. Body Mass Index (BMI) is used to quantify generalised obesity, but does not account for variations in soft tissue distribution. Aims. To define an index quantifying the knee soft tissue depth, utilising underlying bony anatomy, and compare with BMI as a measure of individual patient's knee soft tissue envelopes. We performed a practicality and reproducibility study to validate the Bristol Knee Index for future prospective use. Method. Femoral trans-epicondylar axis, and the proximal tibial plateau width were measured on 225 antero-posterior pre-operative knee radiographs. Corresponding measurements of soft tissue were performed at both levels. These were expressed as a ratio: Soft tissue width (mm)/Bone width (mm) = BKI. Time taken performing each measurement was recorded, and inter- and intra-observer variability was assessed. Results. Average BMI was 32 (18-54). Measuring femoral and tibial BKI averaged 35 seconds. Inter-observer interclass correlation coefficient (ICC) for femoral and tibial BKI was 0.994 and 0.997 respectively. Intra-observer ICC was 0.996 for both. Correlation of BKI to BMI was 0.64 (for both femoral and tibial BKI). When divided into BMI subgroups (normal, overweight, obese, morbidly obese), the correlation was poor. BMI cannot be used to predict the amount of knee soft tissue in the individual patient. Tibial measurement was the most reproducible method. Conclusions. BKI is a fast, reproducible measurement to assess knee soft tissue depth. BMI cannot be used to assess individual patient's knee soft tissue. We plan to correlate BKI to ‘surgical’ orthopaedic complications such as malalignment, wound complications and infection

Introduction. Nonagenarian patients with hip fractures present many challenges to the clinician, both in terms of their advanced age and medical co-morbidities with potential orthopaedic complications. Our aims were to assess outcome of hip fractures in a nonagenarian population with respect to pre-operative predictors of outcome, immediate and long-term morbidity, and survival rates. Methods. Nonagenarian patients with a hip fracture admitted between January 2000 and December 2003 were considered. Eighty-one patients were included, the majority being female (M: F 14: 67). Ages ranged from 90 to 98 years for female patients (mean 92.5 years, SD 2.2) compared to 90 to 95 years for male patients (mean 92.7 years, SD 2). Results. Delay to surgery was 1.25 days and the median ASA grade was III. The majority of patients had intertrochanteric fractures and methods of fixation involved internal fixation in 63% and hemiarthroplasty in the remaining 36% of the group deemed fit for surgery. The rate of complications during inpatient stay was 19% and there were eight inpatient post-operative mortalities due to medical complications. Mean survival post-hip fracture in our patient group was 474.7 days (median 372.5 days). Within forty days of surgery 25% of patients died, including our inpatient mortality of 10%. However, 50% of the patients were still alive 126 days post-operatively. Conclusion. Hip fractures must be given special attention in the nonagenarian population because of their advanced age and medical co-morbidities. Careful pre-operative assessment and medical maximisation combined with prompt surgical intervention yielded a good outcome and return to pre-injury status for most patients. Lower ASA grades, surgery within 48 hours, and increased pre-operative haemoglobin levels were all associated with favourable outcomes

Salvage Total Hip Arthroplasty (THA) presents a viable solution following failed treatment of a hip fracture. Several studies have suggested higher complication rate including high dislocation rate associated with salvage THA. The present study evaluates the results and complications of hip arthroplasty performed as a salvage procedure after the failed treatment of a hip fracture and comparison made to Primary THA in osteoarthritis (OA). Between 1992 and 2007, 53 patients with a mean age of seventy years were treated with THA after the failed treatment of a hip fracture under the care of a single surgeon. The indication for conversion arthroplasty was Avascular necrosis head – 24(45.3%), screw cut out – 6 (11.3%), non-union – 2(3.8%), Displaced fracture – 2(3.8%), Secondary OA – 19 (35.8%). The implants retrieved were Cannulated screws – 3, Sliding plate and screw – 46, Spline plate – 2, Smith Petersons nail – 1, Martin Plate – 1. This group of patients were matched for age, sex, side, and ASA grading with a group of 59 patients who underwent THA for primary osteoarthritis (THA-OA group). Posterior approach was used in all cases. Four patients (7.5%) required grafting of cup and 21 patients (39.6%) required soft tissue release. The average blood loss was 555 ml, mean duration of surgery was 85.5 min, average inpatient stay was 6.7 days. Cemented THA was used in 43 patients and Cementless THA in 10 patients. At one year follow up there were no dislocations, one patient had an undisplaced femoral fracture treated in Spica. Three patients had broken screws; one patient with shortening > 1 inch. There was one revision for deep infection. The mean Harris Hip Score (HHS) improved from 28.4 to 82.5 at one year, while the Oxford Hip score (OHS) improved from 50.9 to 21.9 (Old system). When the scores were compared to the THA-OA group there was no difference in the oxford hip scores and the the mean one year HHS in the THA-OA group was slightly higher than the group with salvage THA, but the difference was not statistically significant. Hip arthroplasty is an effective salvage procedure in patients with prior surgery for hip fracture. Most patients have good pain relief and functional improvement. Despite the operative challenges, remarkably few serious orthopaedic complications were associated with this procedure in the present study

It is unusual, if not unique, for three major research papers concerned with the management of the fractured neck of femur (FNOF) to be published in a short period of time, each describing large prospective randomized clinical trials. These studies were conducted in up to 17 countries worldwide, involving up to 80 surgical centers and include large numbers of patients (up to 2,900) with FNOF. Each article investigated common clinical dilemmas; the first paper comparing total hip arthroplasty versus hemiarthroplasty for FNOF, the second as to whether ‘fast track’ care offers improved clinical outcomes and the third, compares sliding hip with multiple cancellous hip screws. Each paper has been deemed of sufficient quality and importance to warrant publication in The Lancet or the New England Journal of Medicine. Although ‘premier’ journals, they only occationally contain orthopaedic studies and thus may not be routinely read by the busy orthopaedic/surgical clinician of any grade. It is therefore our intention with this present article to accurately summarize and combine the results of all three papers, presenting, in our opinion, the most important clinically relevant facts.

Cite this article: Bone Joint Open 2020;1-6:198–202.

Aims

The aim of this study was to determine the impact of the severity of anaemia on postoperative complications following total hip arthroplasty (THA) and total knee arthroplasty (TKA).