Introduction

Distal femur fracture fixation in elderly presents significant challenges due to osteoporosis and associated comorbidities. There has been an evolution in the management of these fractures with a description of various surgical techniques and fixation methods; however, currently, there is no consensus on the standard of care. Non-union rates of up to 19% and mortality rates of up to 26 % at one year have been reported in the literature. Delay in surgery and delay in mobilisation post-operatively have been identified as two main factors for high rate of mortality. As biomechanical studies have proved better stability with dual plating or nail-plate combination, a trend has been shifting for past few years towards rigid fixation to allow early mobilisation. Our study aims to compare outcomes of distal femur fractures managed with either single plate (SP), dual plating (DP) or nail-plate construct (NP).

Introduction. In recent years, there has been an increase in hip joint replacement surgery using short bone-preserving femoral stem. However, there are very limited data on postoperative periprosthetic fractures after cementless fixation of these stem although the periprosthetic fracture is becoming a major concern following hip replacement surgery. The purpose of this study is to determine incidence of postoperative periprosthetic femoral fractures following hip arthroplasty using bone preserving short stem in a large multi-center series. Materials & Methods. We retrospectively reviewed 897 patients (1089 hips) who underwent primary total hip arthroplasty (THA) or bipolar hemiarthroplasty (BHA) during the same interval (2011–2016) in which any other cementless, short bone-preserving femoral stem was used at 7 institutions. During the study, 1008 THAs were performed and 81 BHAs were performed using 4 different short femoral prostheses. Average age was 57.4 years (range, 18 – 97 years) with male ratio of 49.7% (541/1089). Postoperative mean follow-up period was 1.9 years (range, 0.2 – 7.9 years). Results. Overall incidence of postoperative periprosthetic femoral fractures was 1.1% (12/1089). The mean age of these 12 patients were 71.2 year (range, 43 – 86 years). Seven patients were female and other 5 were male. Time interval between primary arthroplasty and fracture were mean 1.1 years (range, 0.1 – 4.8 years). Injury mechanism is a slip in 10 fractures and fall from 1m or less in 2. Three fractures occurred after BHA while 9 occurred after THA. Four fractures were in type AG and other 8 were in type B1 according to Vancouver classification. Of the 4 with AG type, 2 underwent open reduction and internal fixation and 2 took conservative management. Of the 8 with B1 type, 6 underwent open reduction and internal fixation and 2 took conservative management. Conclusion. The prevalence of postoperative periprosthetic femoral fractures was 1.1% in a multicenter retrospective analysis of 1089 hips. Our findings suggest that postoperative periprosthetic fracture can occur after hip replacement surgery using short bone-preserving stem although the incidence is relatively low

Aims

The aim of this study was to assess the incidence the microbiological spectrum and clinical outcome of hip and knee revision arthroplasties with unexpected-positive-intraoperative-cultures (UPIC) at a single center with minimum follow up of 2 years.

Aim

This study aims to describe our department experience with single stage revision (SSR) for chronic prosthetic-joint infection (PJI) after total hip arthroplasty (THA) between 2005 and 2014 and to analyze success rates and morbidity results of patients submitted to SSR for infected THA according to pathogen.

Background

Fifteen to twenty percent of patients presenting for total hip arthroplasty (THA) have bilateral disease. While simultaneous bilateral THA is of interest to patients and surgeons, debate persists regarding its merits. The majority of previous reports on simultaneous bilateral THA involve patients in the lateral decubitus position, which require repositioning, prepping and draping, and exposure of a fresh wound to pressure and manipulation for the contralateral THA. The purpose of this study was to compare complications, component position, and financial parameters for simultaneous versus staged bilateral THAs using the direct anterior approach (DAA).

Surgical Site Infection (SSI) is one of the most frequent nosocomial infections and depends on many factors: patient, microorganism, antiseptic solution use, antibiotic prophylaxis, hand scrubbing, wound care or hospital stay lenght.

With the present paper the authors aim to study the SSI incidence after Total Knee (TKA) or Hip Arthroplasty (THA).

All patients who underwent primary TKA or THA between January 2011 and May 2012 at our institution were considered. Patients who died within 1 year after the procedure of unrelated causes were excluded. Data collected included ASA classification, type of procedure, total and post-operative hospital stay, type and duration of antibiotic prophylaxis.

Data were collected from the consultation at 1 month and 1 year post-operative, clinical registries and telephone interview. SSI was defined according to the Centers for Disease Control and Prevention criteria. Suspected cases of SSI included antibiotic administration longer than 5 days or absence of antibiotic prescription, hospital stay after the procedure longer than 9 days, patient referring infection symptoms, and clinical data reports of infection or re-intervention.

During the studied period and after exclusion of 5 cases, a total of 251 surgeries (104 TKA, 147 THA) were performed, of which 2 were urgent.

For both TKA and THA, the average total hospital stay was 9 days (8 days post-operative). The majority were American Society of Anesthesiologists (ASA) classification 2 and 3.

There were 4 SSI (1,60%), 2 TKA (1,92%) and 2 THA (1,36%), all of them after discharge. Their average total hospital stay was 10,5 days.

Antibiotic prophylaxis was used in 93% of the patients (97,4% a cephalosporin), with an average length of 5,7 days.

Recommended hospital stay after a TKA or THA is about 5 days. On HELICS-CIRURGIA 2006–2010 report it was 10 days, similar to ours. In infected patients, our total hospital stay was lower (10,5 vs 26).

Recommended duration of antibiotic prophylaxis is 24h. On HELICS-CIRURGIA more than 50% had it for more than 24h, which also happened with us; our antibiotic coverage was similar.

Comparing to HELICS-CIRURGIA, the predominance of ASA 2 and 3 classifications was similar, but the overall SSI rate was lower (1,6% vs 2,24%).

We conclude we must reduce hospital stay and antibiotic duration and keep the surveillance of SSI after TKA or THA.

Background. Post operative analgesia is an important part of Total Knee Arthroplasty (TKA) to facilitate early mobilisation and patient satisfaction. We investigated the effect of periarticular infiltration of the joint with chirocaine local anaesthetic (LA) on the requirement of analgesic in the first 24 hrs period post op. Methods. Retrospective analysis of case notes was carried out on 28 patients, who underwent TKA by two different surgeons. They were divided into two groups of 14 each; who did and did not receive the LA infiltration respectively. All patients were given spinal morphine (162 mcg r: 150-200). Analgesic requirement was assessed in terms of the amount of paracetamol, morphine, diclofenac, oxynorm and tramadol administered in 24hrs post op including the operating time. Results. Following results were obtained from patients receiving LA infiltration vs no infiltration: Morphine; 70 mg vs 200 mg, Paracetamol; 60 gm vs 58 gms, Diclofenac; 1650 mg vs 1050 mg, Oxynorm; 40 mg vs 80 mg, Tramadol; 200 mg vs 400 mg. Average length of stay (LOS) was 6 days (r: 3-8) in both groups. Conclusion. From this study it may be concluded that periarticular LA infiltration reduces the requirement of morphine in first 24 hrs by almost 1/3rd. The amount of tramadol and oxynorm was also halved in LA infiltrated group although the requirement of paracetamol remained the same. LA infiltrated group received almost 1.5 times more Diclofenac as compared to the non infiltrated group. The LOS was not affected by the administration of LA

Conflict in Afghanistan demonstrated predominantly lower extremity and pelvi-perineal trauma secondary to Improvised Explosive Devices (IEDs). Mortality due to pelvic fracture (PF) is usually due to exsanguination. This study group comprised 169 military patients who sustained a PF and lower limb injury. There were 102 survivors and 67 fatalities (39% mortality). Frequent fracture patterns were a widened symphysis (61%) and widening of the sacroiliac joints (SIJ) (60%). Fatality was 20.7% for undisplaced SIJs, 24% for unilateral SIJ widening and 64% fatality where both SIJs were disrupted, demonstrating an increase in fatality rate with pelvic trauma severity. A closed pubic symphysis was associated with a 19.7% mortality rate versus 46% when widened. Vascular injury was present in 67% of fatalities, versus 45% of survivors. Of PFs, 84% were associated with traumatic amputation (TA) of the lower limb. Pelvic fracture with traumatic lower limb amputation presents a high mortality. It is likely that the mechanism of TA and PF are related, and flail of the lower limb(s) is the current hypothesis. This study prompts further work on the biomechanics of the pelvic-lower limb complex, to ascertain the mechanism of fracture. This could lead to evidence-based preventative techniques to decrease fatalities.

Aims. Distraction osteogenesis with intramedullary lengthening devices has undergone rapid development in the past decade with implant enhancement. In this first single-centre matched-pair analysis we focus on the comparison of treatment with the PRECICE and STRYDE intramedullary lengthening devices and aim to clarify any clinical and radiological differences. Methods. A single-centre 2:1 matched-pair retrospective analysis of 42 patients treated with the STRYDE and 82 patients treated with the PRECICE nail between May 2013 and November 2020 was conducted. Clinical and lengthening parameters were compared while focusing radiological assessment on osseous alterations related to the nail’s telescopic junction and locking bolts at four different stages. Results. Osteolysis next to the telescopic junction was observed in 31/48 segments (65%) lengthened with the STRYDE nail before implant removal compared to 1/91 segment (1%) in the PRECICE cohort. In the STRYDE cohort, osteolysis initially increased, but decreased or resolved in almost all lengthened segments (86%) after implant removal. Implant failure was observed in 9/48 STRYDE (19%) and in 8/92 PRECICE nails (9%). Breakage of the distal locking bolts was found in 5/48 STRYDE nails (10%) compared to none in the PRECICE cohort. Treatment-associated pain was generally recorded as mild and found in 30/48 patients (63%) and 39/92 (42%) in the STRYDE and PRECICE cohorts, respectively. Temporary range of motion (ROM) limitations under distraction were registered in 17/48 (35%) segments treated with the STRYDE and 35/92 segments (38%) treated with the PRECICE nail. Conclusion. Osteolysis and periosteal reaction, implant breakage, and pain during lengthening and consolidation is more likely in patients treated with the STRYDE nail compared to the PRECICE nail. Temporary ROM limitations during lengthening occurred independent of the applied device. Implant-related osseous alterations seem to remodel after implant removal. Cite this article: Bone Joint J 2023;105-B(1):88–96

Recent NICE guidelines suggest that Total Hip Arthroplasty (THA) be offered to all patients with a displaced intracapsular neck of femur fracture who: are able to walk independently; not cognitively impaired and are medically fit for the anaesthesia and procedure. This is likely to have significant logistical implications for individual departments.

Data from the National Hip Fracture Database was analysed retrospectively between January 2009 and November 2011. The aim was to determine if patients with displaced intracapsular neck of femur fractures admitted to a single tertiary referral orthopaedic trauma unit received a THA if they met NICE criteria. Case notes were then reviewed to obtain outcome and complication rates after surgery.

Five hundred and forty-six patients were admitted with a displaced intracapsular neck of femur fracture over the described time period. Sixty-five patients met the NICE criteria to receive a THA (mean age 74 years, M:F = 16: 49); however, 21 patients had a THA. The other patients received either a cemented Thompson or bipolar hemiarthroplasty. Within the THA cohort there were no episodes of dislocation, venous thromboembolism, significant wound complications or infections that required further surgery. Within the hemiarthroplasty cohort there was 2 mortalities, 2 implant related infections, 1 dislocation and 2 required revision to a THA.

There is evidence to suggest better outcomes in this cohort of patients, in terms pain and function. There is also a forecasted cost saving for departments, largely due to the relative reduction in complications. However, there were many cases (44) in our department, which would have been eligible for a THA, according to the NICE guidelines, who received a hemiarthroplasty. This is likely a reflection of the increased technical demand, and larger logistical difficulties faced by the department. We did note more complications within the hemiarthroplasty group, however, the numbers are too small to address statistical significance, and a longer follow up would be needed to further evaluate this. There is a clear scope for optimisation and improvement of infrastructure to develop time and resources to cope with the increased demand for THA for displaced intracapsular neck of femur fractures, in order to closely adhere to the NICE guidelines.

A retrospective review of 51 consecutive patients undergoing fixation of Scaphoid fractures by two surgeons in a single institution was conducted. Twenty-four patients were treated with a Herbert screw and twenty-seven with an Acutrak screw. This included six patients who underwent acute fixation, three in each group. The remaining cases were for the treatment of non-union and delayed union.

There were no significant differences between the two groups in terms of age, side of injury, and mechanism of injury. Fractures were classified as proximal, middle and distal thirds of the Scaphoid and there was no significant difference between the groups regarding the types of fractures treated. The only significant difference between the groups was the time from injury to fixation when considering the cases of delayed union and non union which was greater in the Herbert screw group (7.5 months vs 4 months p=<0.05).

There was no significant difference in outcome between the two methods of fixation. Union rates for all cases were 79% for Herbert screws and 81% for Acutrak screws and 82% and 83% respectively when only considering the delayed union/non-union procedures. There was no difference in terms of time to union, further surgery or clinical outcome between the two groups. The Acutrak screw required removal in five patients and the Herbert screw in two due to symptoms from screw prominence. This was not statistically significant.

In conclusion there is no significant difference in surgical outcome between these two methods of fixation for Scaphoid fractures. The authors feel that this supports the view that biological factors are more important than the method of fixation in obtaining union of Scaphoid fractures.

Of the 6075 patients enrolled in EU-CORE registry, 206 patients had orthopaedic device-related infections. Significant underlying diseases were reported in 71% patients, most frequently cardiovascular disease (38%). The common sites of infection were knee (40%) and hip (33%). Among the 170 patients with available culture results, 135 (79%) were positive. Coagulase-negative staphylococci (CoNS, 44%) and Staphylococcus aureus (43%, of those 47% were methicillin resistant) were the most commonly isolated pathogens. Daptomycin was used empirically in 48% patients and as second-line therapy in 67% patients. During daptomycin therapy, 67% patients had undergone surgery (debridement, 61%; removal of foreign device, 39%; incision and drainage, 9%). Over half of the inpatients (54%) received concomitant antibiotics. Daptomycin was most frequently prescribed at a dose of 6 mg/kg/day (48%), with a median duration of therapy of 16 (range, 1–176) days. The overall clinical success rate was 85%, and was similar whether daptomycin was administered as first- or second-line therapy. The success rates achieved for infections caused by S. aureus and CoNS were 86% and 83%, respectively. Among the 79 patients who entered the long-term follow-up, 85% had a sustained response. Adverse events (AEs) and serious AEs possibly related to daptomycin were reported in 4.4% and 1.9% patients, respectively.

Results from this real-world clinical experience showed that daptomycin is an effective and well-tolerated treatment option for orthopaedic device-related infections with a high success rate up to 2 years of follow-up.

Objective

To evaluate functional and oncological outcomes following sacral resection

Time at the surgical ‘coal-face’ has been reduced by introduction of the European Working Time Directive (EWTD) significantly impacting training opportunity. Our null hypothesis was that duration of surgery is significantly longer if a trainee were performing the operation despite supervision or level of trainee experience.

Cemented hip hemiarthroplasty was chosen as our index procedure as complexity is largely comparable between cases. 461 patients were identified on the hospital trauma database. Data were augmented by information regarding level of surgeon, assistant and time of surgery from the hospital theatre database.

There was no significant difference in registrar and consultant operative times, mean time 69 and 72 minutes respectively. SHOs were significantly slower (mean 80 minutes, p=0.0006). Junior (ST5 or less) registrars were significantly slower (mean 81minutes, p=0.0002) whereas senior registrars were not. Supervision level had no effect on duration of senior registrar operations but when junior registrars were consultant supervised they were not significantly slower (mean 75 minutes, p=0.09).

Supervised operating therefore reduces time variability and should be promoted within a climate of training. Increase in mean operative time in registrars and SHOs is insignificant within a day's operating and is unlikely to lead to cancellations of cases.

Aims. The new COVID-19 variant was reported by the authorities of the UK to the World Health Organization (WHO) on 14 December 2020. We aim to describe the clinical characteristics and nosocomial infection rates in major trauma and orthopaedic patients comparing the first and second wave of COVID-19 infection. Methods. A retrospective analysis of a prospectively collected trauma database was reviewed at a level 1 major trauma centre from 1 December 2020 to 18 February 2021 looking at demographics, clinical characteristics, and nosocomial infections and compared to our previously published first wave data (26 January 2020 to 14 April 2020). Results. From 1 December 2020 to 18 February 2021, 522 major trauma patients were identified with a mean age of 54.6 years, and 53.4% (n = 279) were male. Common admissions were falls (318; 60.9%) and road traffic accidents (RTAs; 71 (13.6%); 262 of these patients (50.2%) had surgery. In all, 75 patients (14.4%) tested positive for COVID-19, of which 51 (68%) were nosocomial. Surgery on COVID-19 patients increased to 46 (61.3%) in the second wave compared to 13 (33.3%) in the first wave (p = 0.005). ICU admissions of patients with COVID-19 infection increased from two (5.1%) to 16 (20.5%), respectively (p = 0.024). Second wave mortality was 6.1% (n = 32) compared to first wave of 4.7% (n = 31). Cardiovascular (CV) disease (35.9%; n = 14); p = 0.027) and dementia (17.9%; n = 7); p = 0.030) were less in second wave than the first. Overall, 13 patients (25.5%) were Black, Asian and Minority ethnic (BAME), and five (9.8%) had a BMI > 30 kg/m. 2. The mean time from admission to diagnosis of COVID-19 was 13.9 days (3 to 44). Overall, 12/75 (16%) of all COVID-19 patients died. Conclusion. During the second wave, COVID-19 infected three-times more patients. There were double the number of operative cases, and quadruple the cases of ICU admissions. The patients were younger with less dementia and CV disease with lower mortality. Concomitant COVID-19 and the necessity of major trauma surgery showed 13% mortality in the second wave compared with 15.4% in the first wave. In contrast to the literature, we showed a high percentage of nosocomial infection, normal BMI, and limited BAME infections. Cite this article: Bone Jt Open 2021;2(8):661–670

Aims

The principles of evidence-based medicine (EBM) are the foundation of modern medical practice. Surgeons are familiar with the commonly used statistical techniques to test hypotheses, summarize findings, and provide answers within a specified range of probability. Based on this knowledge, they are able to critically evaluate research before deciding whether or not to adopt the findings into practice. Recently, there has been an increased use of artificial intelligence (AI) to analyze information and derive findings in orthopaedic research. These techniques use a set of statistical tools that are increasingly complex and may be unfamiliar to the orthopaedic surgeon. It is unclear if this shift towards less familiar techniques is widely accepted in the orthopaedic community. This study aimed to provide an exploration of understanding and acceptance of AI use in research among orthopaedic surgeons.

Over the last 10 years atypical femoral fractures (AFFs) have become recognised as a complication of standard-dose bisphosphonate use. In 2014 the American Society for Bone and Mineral Research published updated diagnostic criteria for AFF. We undertook a 5-year retrospective analysis of the trauma admission database at a major trauma centre to establish the incidence of this problem in our patient population. Initial screening was performed using keyword-matching methodology to produce a shortlist of patients with low-energy femoral fractures. These patients’ case notes, radiographs, and electronic discharge summaries were reviewed to discriminate AFF from typical femoral fractures. Initial filtering identified a total of 112 low energy femoral fractures. Of these, 12 were confirmed as AFFs. 58% (7/12) of the AFF group were on bisphosphonates compared to 15% (15/100) of the typical femoral fracture group. This finding was statistically significant (p = 0.0004). These data show that there is a link between bisphosphonate use and AFF. However, a causal relationship cannot be inferred. The incidence of AFF in our study is broadly in line with the published data

Segmental excision of long-bone sarcomas can require complex reconstruction, often resulting in the use of prosthetic replacements at a young age. The use of vascularised free fibula grafting (VFFG) is well established as a reconstruction modality in sarcoma surgery. Aims. To analyse the experience of two European sarcoma centres and their use of vascularised free fibula grafting as a primary and revision procedure in limb salvage for diaphyseal long-bone defects in sarcoma surgery. Methods. A retrospective analysis was carried out of 70 consecutive patients undergoing VFFG between 1996 and 2009 under the Oxford Sarcoma Service (Nuffield Orthopaedic Centre) and the Dutch Orthopaedic Tumour Society (Leiden University Hospital). Clinical and radiological assessments were made and functional outcome scores collected. Results. 70 patients, 42 male, with a mean age of 20 years (3–61) received a VFFG (a primary procedure in 76%) and underwent mean follow up of 82 months (11–181). 83% of grafts were located in the lower extremity with 71% resulting from reconstruction of malignant tumours. VFFGs with a mean length of 17.4 cm (6–25) were used to reconstruct defects with a mean length of 13.5 cm (8–21). 92% of VFFGs achieved union at mean of 59 weeks (16–250). Predictors for non-union included defects greater than 12cm, malignant disease processes and an immature skeleton. 65% of patients had at least one complication with 51% requiring at least one revision procedure, although only 3 required removal of the graft (2 endoprosthetic replacements and 1 amputation). Mean MSTS score at final follow-up was 26.7 (20–30). Conclusion. The vascularised free fibula graft has been proven to provide a stable reconstruction of bony defects after tumor resection and results in a functional extremity, however it is accompanied by a high risk of complications and revision surgery

In 2020, the COVID-19 pandemic meant that proceeding with elective surgery was restricted to minimise exposure on the wards. In order to maintain throughput of elective cases, our hospital was forced to convert as many cases as possible to same day procedures rather than overnight admission. In this retrospective analysis we review the cases performed as same day arthroplasty surgeries compared to the same period 12 months previous. We conducted a retrospective analysis of patients undergoing total hip and knee arthroplasties in a three month period between October and December in 2019 and again in 2020, in the middle of the SARS-CoV-2 pandemic. Patient demographics, number of out-patient primary arthroplasty cases, length of stay for admissions, 30-day readmission and complications were collated. In total, 428 patient charts were reviewed for the months of October-December of 2019 (n=195) and 2020 (n=233). Of those, total hip arthroplasties comprised 60% and 58.8% for 2019 and 2020, respectively. Demographic data was comparable with no statistical difference for age, gender contralateral joint replacement or BMI. ASA grade I was more highly prevalent in the 2020 cohort (5.1x increase, n=13 vs n=1). Degenerative disc disease and fibromyalgia were less significantly prevalent in the 2020 cohort. There was a significant increase in same day discharges for non-DAA THAs (2x increase) and TKA (10x increase), with a reciprocal decrease in next day discharges. There were significantly fewer reported superficial wound infections in 2020 (5.6% vs 1.7%) and no significant differences in readmissions or emergency department visits (3.1% vs 3.0%). The SARS-CoV-2 pandemic meant that hospitals and patients were hopeful to minimise the exposure to the wards and to not put strain on the already taxed in-patient beds. With few positives during the Coronavirus crisis, the pandemic was the catalyst to speed up the outpatient arthroplasty program that has resulted in our institution being more efficient and with no increase in readmissions or early complications

The second wave of COVID-19 infections in 2021 resulting from the delta strain had a significantly larger impact on the state of New South Wales, Australia and with it the government implemented harsher restrictions. This retrospective cohort study aims to explore how the increased restrictions affected hand trauma presentations and their treatment. Retrospective analysis was performed on patients who underwent hand surgery from the period of June 23 – August 31 in 2020 and 2021 at a level one trauma centre in Western Sydney. During the second-wave lockdown there was an 18.9% decrease in all hand trauma presentations. Despite widespread restrictions placed on the manufacturing, wholesale, retail and construction industries, there was an insignificant difference in work injuries. Stay-at-home orders and reduced availability of professional tradespersons likely contributed to an increase in DIY injuries. Significant reductions in metacarpal and phalangeal fractures coincided with significantly curtailed sporting seasons. The findings from this study can assist in predicting the case-mix of hand trauma presentations and resource allocation in the setting of future waves of COVID-19 and other infectious diseases