Acromial morphology has been implicated as a risk factor for unidirectional posterior shoulder instability. Studies utilising plain film radiographic landmarks have identified an increased risk of posterior shoulder dislocation in patients with higher acromion positioning. The aims of this study were to develop a reproducible method of measuring this relationship on cross sectional imaging and to evaluate acromial morphology in patients with and without unidirectional posterior shoulder instability. We analysed 24 patients with unidirectional posterior instability. These were sex and age matched with 61 patients with unidirectional anterior instability, as well as a control group of 76 patients with no instability. Sagittal T1 weighted MRI sequences were used to measure posterior acromial height relative to the scapular body axis (SBA) and long head of triceps insertion axis (LTI). Two observers measured each method for inter-observer reliability, and the intraclass correlation coefficient (ICC) calculated. LTI method showed good inter-observer reliability with an ICC of 0.79. The SBA method was not reproducible due suboptimal MRI sequences. Mean posterior acromial height was significantly greater in the posterior instability group (14.2mm) compared to the anterior instability group (7.7mm, p=0.0002) as well when compared with the control group (7.0mm, p<0.0001). A threshold of 7.5mm demonstrated a significant increase in the incidence of posterior shoulder instability (RR = 9.4). We conclude that increased posterior acromial height is significantly associated with posterior shoulder instability. This suggests that the acromion has a role as an osseous restraint to posterior shoulder instability

Aim. Fracture-related infection (FRI) is a severe post-traumatic complication which can be accompanied with a soft-tissue defect or an avital soft-tissue envelope. In these cases, a thoroughly planned orthoplastic approach is imperative since a vital soft-tissue envelope is mandatory to achieve fracture union and infection eradication. The aim of our study was to analyse plastic surgical aspects in the management of FRIs, including the type and outcome of soft-tissue reconstruction (STR), and to investigate the long-term outcome of FRI after STR. Method. Patients with a lower leg FRI requiring STR that were treated from 2010 to 2018 at our center were included in this retrospective analysis. STR involved the use of local, pedicled and free flaps. The primary outcome was the success rate of STR, and the secondary outcome was long-term fracture consolidation and cure of infection. Results. Overall, 145 patients with lower leg FRI were identified, of whom 58 (40%) received STR. Muscle flaps were applied in 38, fascio-cutaneous flaps in 19 and a composite osteo-cutaneous flap in one case. All patients underwent successful STR (primary STR in 51/58 patients, 7/58 patients needed secondary STR). A high Charlson Comorbidity Index Score was a significant risk factor for flap failure (p=0.011). Patients with free-flap STR developed significantly more severe complications and needed more surgical interventions (Clavien-Dindo ≥IIIa; p=0.001). Out of the 43 patients that completed long-term follow-up (mean 24 months), fracture consolidation was achieved in 32 and infection eradication in 31. Polymicrobial infection was a significant risk factor for fracture non-union (p=0.002). American Society of Anesthesiologists (ASA) classification of 3 or higher (p=0.040) was a risk factor for persistence or recurrence of infection. Conclusions. In our population, 58/145 patients with FRI required STR. STR was successful in all patients eventually, in 7/58 patients secondary STR was necessary. Therefore, STR should be sought even if primary STR fails. Despite successful STR, the long-term composite outcome showed a high rate of failed fracture consolidation and failed eradication of infection, which was independent of primary STR failure

Surgical site infections (SSIs) after spinal fusion surgery increase healthcare costs, morbidity and mortality. Routine measures of obesity fail to consider site specific fat distribution. We aimed to assess the association between the spine adipose index and deep surgical site infection and determine a threshold value for spine adipose index that can assist in preoperative risk stratification in patients undergoing posterior instrumented lumbar fusion (PILF). A multicentre retrospective case-control study was completed. We reviewed patients who underwent PILF from January 1, 2010 to December 31, 2018. All patients developing a deep primary incisional or organ-space SSI within 90 days of surgery as per US Centre for Disease Control and Prevention criteria were identified. We gathered potential pre-operative and intra-operative deep infection risk factors for each patient. Spine adipose index was measured on pre-operative mid-sagittal cuts of T2 weighted MRI scans. Each measurement was repeated twice by three authors in a blinded fashion, with each series of measurement separated by a period of at least six weeks. Forty-two patients were included in final analysis, with twenty-one cases and twenty-one matched controls. The spine adipose index was significantly greater in patients developing deep SSI (p =0.029), and this relationship was maintained after adjusting for confounders (p=0.046). Risk of developing deep SSI following PILF surgery was increased 2.0-fold when the spine adipose index was ≥0.51. The spine adipose index had excellent (ICC >0.9; p <0.001) inter- and intra-observer reliabilities. The spine adipose index is a novel radiographic measure and an independent risk factor for developing deep SSI, with 0.51 being the ideal threshold value for pre-operative risk stratification in patients undergoing PILF surgery

Malnutrition is an important consideration during the perioperative period and albumin is the most common laboratory surrogate for nutritional status. The purpose of this study is to identify if preoperative serum albumin measurements are predictive of infection following arthroscopic procedures. Patients undergoing knee, shoulder or hip arthroscopy between 2006–2016 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Patients with an arthroscopic current procedural terminology code and a preoperative serum albumin measurement were included. Patients with a history of prior infection, including a non-clean wound class, pre-existing wound infection or systemic sepsis were excluded. Independent t-tests where used to compare albumin values in patients with and without the occurrence of a postoperative infection. Pre-operative albumin levels were subsequently evaluated as predictors of infection with logistic regression models. There were 31,906 patients who met the inclusion criteria. The average age was 55.7 years (standard deviation (SD) 14.62) and average BMI was 31.7 (SD 7.21). The most prevalent comorbidities were hypertension (49.2%), diabetes (18.4%) and smoking history (16.9%). The average preoperative albumin was 4.18 (SD 0.42). There were 45 cases of superficial infection (0.14%), 10 cases of wound dehiscence (0.03%), 17 cases of deep infection (0.05%), 27 cases of septic arthritis or other organ space infection (0.08%) and 95 cases of any infection (0.30%). The preoperative albumin levels for patients who developed septic arthritis (mean difference (MD) 0.20, 95% CI, 0.038, 0.35, P = 0.015) or any infection (MD 0.14, 95% CI 0.05, 0.22, P = 0.002) were significantly lower than the normal population. Additionally, disseminated cancer, Hispanic race, inpatient status and smoking history were significant independent risk factors for infection, while female sex and increasing albumin were protective towards developing any infection. Rates of all infections were found to increase exponentially with decreasing albumin. The relative risk of infection with an albumin of 2 was 3.46 (95% CI, 2.74–4.38) when compared to a normal albumin of 4. For each albumin increase of 0.69, the odds of developing any infection decreases by a factor of 0.52. This study suggests that preoperative serum albumin is an independent predictor of septic arthritis and all infection following elective arthroscopic procedures. Although the effect of albumin on infection is modest, malnutrition may represent a modifiable risk factor with regard to preventing infection following arthroscopy

The incidence of total shoulder arthroplasty (TSA) in increasing. Evidence in primary hip and knee arthroplasty suggest that preoperative opioid use is a risk factor for postoperative complication. This relationship in TSA is unknown. The purpose of this study was to investigate this relationship. The Truven Marketscan claims database was used to identify patients who underwent a TSA and were enrolled for 1-year pre- and post-operatively. Preoperative opioid use status was used to divide patients into cohorts based on the number of preoperative prescriptions received. An ‘opioid holiday’ group (patients with a preoperative, 6-month opioid naïve period after chronic use) was also included. Patient information and complication data was collected. Univariate and multivariate logistic regression were then performed. Fifty-six percent of identified patients received preoperative opioids. Multivariate analysis demonstrated that patients on continuous preoperative opioids (compared to opioid naïve) had higher odds of: infection (OR 2.34, 95%CI 1.62–3.36, p<0.001), wound complication (OR 1.97, 95%CI 1.18–3.27, p=0.009), any prosthetic complication (OR 2.62, 95%CI 2.2–3.13, p<0.001), and thromboembolic event (OR 1.42, 95%CI 1.11–1.83, p=0.006). The same group had higher healthcare utilization including extended length of stay, non-home discharge, readmission, and emergency department visits (p<0.001). This risk was reduced by a preoperative opioid holiday. Opioid use prior to TSA is common and is associated with increased complications and healthcare utilization. This increased risk is modifiable, as a preoperative opioid holiday significantly reduced postoperative risk. Therefore, preoperative opioid use represents a modifiable risk factor

Introduction. Failure of acetabular components has been reported to lead to large bone defects, which determine outcome and management after revision total hip arthroplasty (THA). Although Kerboull-type (KT) plate (KYOCERA Medical Corporation, Kyoto, Japan) has been used for compensating large bone loss, few studies have identified the critical risk factors for failure of revision THA using a KT plate. Therefore, the aim of this study is to evaluate the relationship between survival rates for radiological loosening and the results according to bone defect or type of graft. Patients and methods. This study included patients underwent revision THA for aseptic loosening using cemented acetabular components with a KT plate between 2000 and 2012. Bone defects were filled with beta Tricalcium phosphate (TCP) granules between 2000 and 2003 and with Hydroxyapatite (HA) block between 2003 and 2009. Since 2009, we have used femoral head balk allografts. Hip function was evaluated by using the Japanese Orthopaedic Association (JOA) score and University of California, Los Angeles (UCLA) activity. Acetabular defects were classified according to the American Academy of Orthopedic Surgeons (AAOS) classification. The postoperative and final follow-up radiographs were compared to assess migration of the implant. Kaplan–Meier method for cumulative probabilities of radiographic failure rate, and the comparison of survivorship curves for various subgroups using the log-rank test were also evaluated. Logistic regression was performed to examine the association of such clinical factors as the age at the time of operation, body mass index, JOA score, UCLA activity score, and AAOS classification with radiographic failure. Odds ratios (ORs) and 95% CIs were calculated. Multivariate analysis was performed to adjust for potential confounders by clinical factors. Values of p < 0.05 were considered significant. Results. The patient background is shown in Table 1. The JOA score at the final follow-up increased significantly (p < 0.001). Radiographic failure was evaluated for revision THA with beta-TCP, HA, and bulk allografts. These survival rates are shown in Table 2 and the rate in the AAOS type IV group was significantly lower than that in the type III group (p = 0.033). The survival curves were significantly different between beta -TCP group and bulk allograft group (p = 0.036) (Table 3). Multivariate analysis showed that AAOS type IV defect was found to be a risk factor for radiographic failure (radiographic failure: OR: 15.5, 95% CI: 1.4–175.4, p = 0.032). Discussion. Our results of survival rate are similar to those reported by previous studies. However, by comparing the survival rates between beta-TCP group and bulk allograft group, beta-TCP is not suitable for bone graft reconstruction of acetabular bone defects with a KT plate. We also found that AAOS type IV to be a risk factor for failure of revision THA. Therefore, bone defect size is the critical risk factor for failure of revision THA using a KT plate. New devices and techniques for KT plates are needed to improve the treatment of pelvic discontinuity

Aim. Success rate of debridement, antimicrobial and implant retention (DAIR) in high suspicion of early PJI after primary arthroplasty is 70–80%. No studies have been performed focusing on outcome of DAIR after revision arthroplasty of the hip (THA) or knee (TKA). The aim of this study is to investigate the outcome of DAIR in suspected early PJI after revision THA or TKA and to identify risk factors for failure. Method. In this retrospective study, we identified early DAIRs after revision THA or TKA performed between January 2012 and August 2019. All patients received empirical antibiotics directly after the DAIR procedure. Antimicrobial treatment was adjusted to the tissue culture results. Success was defined as: 1) implant retention; 2) no repeated revision arthroplasty or supervised neglect after treatment; 3) no persistent or recurrent PJI after treatment and no administration of suppressive antimicrobial therapy; 4) survival of the patient. Infection free success was defined as: 1) no persistent or recurrent PJI after treatment; 2) no administration of suppressive antimicrobial therapy. Results. The overall success rate after one year of 100 cases with early DAIR after revision THA or TKA was 79% and infection free success rate was 85%. In PJI cases, empirical antimicrobial mismatch with causative micro-organisms was associated with lower success rate (70%) than non-mismatch (95%) (p=0.02). No patients from the non-PJI group failed after one year versus 13 failures within the PJI group. A consecutive DAIR within 90 days after the first DAIR was warranted in 24 cases. Only 4 of 20 PJI cases failed despite the consecutive DAIR. Conclusions. In high suspicion of early PJI after revision arthroplasty, DAIR is a good treatment option with comparable outcome with DAIR after primary arthroplasty. A consecutive DAIR should not be avoided when infection control fails within 90 days after the first DAIR to prevent explantation of the prosthesis. Antimicrobial mismatch is associated with failure and should be avoided

Introduction. Urinary catheterisation can cause bacteraemia and therefore may be associated with a risk of infection in hip and knee arthroplasty. However postoperative urinary retention can be distressing for the patient. This study investigates the factors that might predict the need for postoperative catheterisation in order to help develop a protocol to decide who should be electively catheterised. Methods. A prospective blinded study of 128 consecutive patients undergoing lower limb arthroplasty was carried out. No patient underwent perioperative catheterisation. Data obtained included sex, age, joint (hip or knee replacement), prostate score (IPSS), previous urinary retention, comorbidities and residual bladder volume after attempted complete voiding measured using an ultrasound bladder scanner. The type of anaesthesia and the requirement for urinary catheterisation postoperatively were recorded. Predictive risk factors were identified using binary logistic regression, and expressed as odds ratios (OR) and 95% confidence intervals (CI). Results. The mean age was 69.5 years (SD 8.9). There were 56 males and 72 females. 38 patients (30%) required postoperative catheterisation. Logistic regression identified the following predictive risk factors: bladder scan volume per ml increase (OR 1.006; CI 1.000–1.012); male sex (OR 5.51; CI 2.01–15.16); previous catheter (OR 4.26; CI 1.53–11.82); spinal/epidural/combined spinal epidural (CSE) anaesthesia (OR 6.78; CI 1.75–26.32); moderate IPSS score (OR 5.15; CI 1.73–15.37); severe IPSS score (OR 3.53; CI 0.605–20.54). The specificity of our model is 91%, the positive predictor value 71% and negative predictor value 82%. Discussion. Post-voiding bladder scan volume (1ml increase = 0.6% increased risk), male sex, history of retention, medium or high IPSS score and an epidural, spinal or CSE anaesthetic are independent risk factors that can be used preoperatively to predict the likelihood of postoperative retention

Background:. There is limited evidence regarding HIV infection as a risk factor for delayed union and implants sepsis in patient with fractures treated with surgical fixation. Most studies have included patient with a variety of different fractures and hence very different risks regarding delayed union and implant sepsis. We have looked at a single fracture, closed femoral shaft fractures treated with intramedullary nailing, to see if HIV infection is a risk factor with for the development of delayed union and implant sepsis. We present a prospective study of 160 patients with closed femoral shaft fractures treated with intramedullary nailing. Primary outcomes were delayed union of more than 6 months and implant sepsis in the first 12 months. Methods:. From February 2011 until November 2012 all patient with closed femoral shaft fractures treated at our hospital were included in the study. Patients were tested for HIV infection and a number of clinical parameters were documented, including: AO fracture score, duration of surgery, level of training of surgeon, comorbidities, CD4 count, high energy injury and number of operations. Results:. Forty (25%) patients were HIV positive. Seven patients had CD4 counts below 350 cells/µL and 12 patients were on ARV's. Four (3%) patients developed implants sepsis and of these 1 (25%) was HIV positive. Two (1%) patients had a delayed union of more than 6 months and both these patients were HIV negative. Conclusion:. HIV is not a risk factor for delayed union and implant sepsis in the first 12 months after surgery. Intramedullary nailing is a safe and effective in the treatment of HIV positive patients with closed femur fractures

Anthropometric anatomical factors may influence mechanical and functional stability of joints. An increased posterior tibial slope places the anterior cruciate ligament at a theroretical biomechanical disadvantage. An increased posterior tibial slope can potentially alter forces during landing tasks by either increasing anterior tibial translation and/or ACL loading. The purpose of this study is to investigate the relationship between posterior tibial slope and anterior cruciate ligament injuries. It is hypothesised that subjects with an ACL injury have an increased posterior tibial slope compared to a normal population. Posterior tibial slope in 211 patients (154 male, 57 female), aged 15–49, who underwent anterior cruciate ligament reconstruction was measured using the posterior tibial cortex as reference. A matched control group was used for comparison. The average posterior tibial slope in the ACLR population was 6.1 degrees, whilst the control group had average values of 5.4 degrees. This finding nearly reached statistical significance (p=0.057). In the male population, average values were 5.5 degrees in the ACLR group and 5.9 in the control group. This was not significant (p=0.21). However, there was a significant difference (p=0.04) in the female group. ACLR females had higher values 6.5 degrees whereas the control group had average values of 5.2 degrees. Increased posterior tibial slope decreases the inclination of the ACL and potentially decreases vector force during dynamic tasks. We could not confirm the results of previous studies demonstrating an increased degree of posterior tibial slope in ACL injured patients. However, we demonstrated a significant difference in tibial slope in females. Based on our results, an increased posterior tibial slope is not a risk factor in males but possibly contributes to ACL injuries in females. Increased posterior tibial slope may be one of the reasons why females have a higher incidence of ACL injuries

Background. There is a lack of information on the independent preoperative predictors of perioperative mortality, including the influence of previous stroke and acute coronary syndromes (myocardial infarction + unstable angina, ACS). Previous studies have grouped variables under the umbrella term “ischaemic heart disease”. In this study, we investigated the influence of vascular risk factors separately. Methods. The Hospital Episode Statistics database was analyzed for elective admissions for total hip (THR) and total knee (TKR) replacements between 2004 and 2009. Independent preoperative predictors of perioperative outcome were identified from admission secondary diagnosis codes. Perioperative mortality was defined as 30-day in-hospital death. Logistic regression analysis was used to identify independent predictors of 30-day mortality. Data was adjusted for age, social deprivation and Charlson co-morbidity score. Results. 414,985 THRs and TKRs were performed in the study period. There were 829 deaths within 30 days (0.2%). Previous ACS (OR: 1.73 [1.33 to 2.25]) and stroke (OR: 1.64 [1.02 to 2.65]) predicted 30-day mortality. ACS (OR: 3.81 [1.55 to 9.34]) within six months of THKR surgery was associated with increased odds of perioperative mortality. The effect of ACS persisted up to 12 months (OR: 1.99 [1.02 to 3.88]). Renal failure, liver disease, heart failure, peripheral vascular disease and non-atrial fibrillation arrhythmia also increased the odds of mortality. Discussion. Previous stroke and ACS increase the odds of perioperative mortality, together with several other vascular risk factors. Within 12 months of ACS, risk of mortality is significantly elevated. Elective surgery should be avoided in this period

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

Purpose. Glenoid version has been correlated with tears within the rotator cuff. Cuff tear arthropathy is an evolution of multiple unhealed tendons ultimately resulting in pseudoparalysis. Although several factors are critical to allow tendon healing, we have observed that there is less glenoid version in patients with cuff tear arthropathy. This was compared to those with osteoarthritis where rotator cuff tears are uncommon. We hypothesize that patients undergoing inverse prosthesis generally have a near neutral glenoid. Method. A single surgeons practice (JPW) was retrospectively reviewed for all cuff tear arthropathy and osteoarthritis patients undergoing primary shoulder arthroplasty. (Zimmer, Warsaw, IN). Glenoid version was measured by 2 fellowship trained shoulder surgeons. Inter and intra-class correlation was measured. Results. The axial CT scans of 84 patients (cuff tear arthropathy and osteoarthritis) were evaluated. Inter and intra-class correlation was excellent (0.96, 0.97). Glenoid version was between 4.1 +/− 3.6 and 16.5 +/− 8.6 degrees for cuff tear arthropathy and osteoarthritis, respectively (p < 0.0001). Conclusion. Our observation of near neutral glenoid version in patients with cuff tear arthropathy has not been reported in the literature. The anatomical version of the glenoid may be a risk factor in patients undergoing rotator cuff repair. This may predispose certain individuals to cuff tear arthropathy compared to those with increased retroversion

Introduction. The goal of treating artificial joint infection is to relieve the infection quickly and re-establish joint function, but many patients have underlying diseases, and treatment is often made problematic by the diversity of the causative bacteria. In this study we assessed the factor that enabled revision arthroplasty in patients with infection after artificial hip arthroplasty, including bipolar hip arthroplasty, in our hospital. Subjectives and Methods. The subjects were the 16 patients (16 hips) with infection after hip arthroplasty who were treated in our hospital during the past 10 years. There were 7 males and 9 females, and their mean age was 69.8 years. Primary total hip arthroplasty had been performed in 6 hips, revision hip arthroplasty in 8 hips, and bipolar hip arthroplasty in 2 hips. Infected implants were removed as soon as possible and delayed reimplantations with an interval antibiotic spacer were attempted in all patients. 9 hips were successful in reimplantation (reimplantation group) and 7 hips were impossible (No reimplantation group). In this study we investigated age, complications, body mass index (BMI), body temperature, pain, rate of resistant bacteria, number of hip surgery prior to infection and clinical manifestations compared to two groups. Results. Age, rate of resistant bacteria, body temperature and number of surgery were not significantly different compared to two groups. In no reimplantation group BMI was significantly low. Also, local heat, redness and fistula as clinical manifestations had been observed in most no reimplantation hips. Conversely there were no associations with the presence or absence of swelling, tenderness and pain in initial consultation. Discussion. Garvin et al. have reported a two-stage reimplantation success rate for infected artificial joints of 91%. However, our results comparatively showed lower successful rate. It is suggested that lower BMI, presence of local heat, redness and fistulation were risk factors for reimplantation. Especially, these clinical manifestations means that the infection widely invade to subcutaneous tissue. Therefore, we should performed debridement and antibiotic treatment more carefully

Introduction. Excessive soft tissue swelling will delay surgery for a proportion of patients admitted with ankle fractures. Surgical and anesthetic teams may waste time assessing patients destined to be cancelled due to swelling. The aim of this investigation was to determine factors associated with cancellation. Methods. Case notes of 87 patients (46 male, 41 female), mean age 43 years (range, 13 to 80) who underwent ankle fracture fixation were retrospectively analysed. 31 of 87 ankles (36%) were unsuitable for day after admission surgery due to swelling. Factors investigated included age, gender, mechanism of injury, fracture configuration and necessity for reduction on arrival in the emergency department due to dislocation; each factor was independently analysed for significance using Fisher's exact test. Results. Ankle fractures associated with a higher energy injury such as sports, falls from height and road traffic accidents were significantly more likely than simple slips to be cancelled due to excess swelling the following morning (p = 0.053). Tri- or bi-malleolar ankle injuries and fracture dislocations requiring manipulation in the emergency department were also significant risk factors for cancellation (p = 0.004 and p = 0.002 respectively). Patients presenting with at least two of these factors demonstrated a 71% probability of cancellation the following day (17 of 87 patients). Presence of three risk factors increased the probability of cancellation to 100% (3 of 87 patients). Conclusion. Cancellation on the day of surgery wastes time and causes patient distress. During busy on-call periods patients with all three risk criteria will almost certainly be too swollen for next day surgery. With the proviso that these fractures are immobilised in an acceptable position, patients could be rested with elevation and rebooked for surgery as opposed to being assessed and subsequently cancelled due to soft tissue swelling the day after injury

Background. Sciatic nerve palsy is a relatively rare, but one of the serious complications after total hip arthroplasty (THA). The prevalence of nerve palsy after THA has been reported to range from 0.3% to 3.7%. Previous authors have speculated that causes could include overlengthening, compression from a hematoma, from extruded metylmethacrylate, or from retractor placement, or laceration from a screw used in the acetabular component. Leg lengthening more than 4 cm was associated with sciatic nerve palsy in the past literature. But there is no report about maximum safety leg lengthening to prevent sciatic nerve palsy significantly. The purpose of this study was to identify the safety rage of leg lengthening to prevent sciatic nerve palsy in THA for the patients with adult hip dislocation. Methods. Forty two consecutive patients47 jointswith Crowe type â?¢ or â?£ were performed THA. Nine joints were Crowe type â?¢ and thirty eight joints were type â?£ in this study. All patients were female. The average age at the time of surgery was 63.3 years (range, 40–77 years). The average patient body weight was 50.5 kg and the average height was 150 cm (body mass index: 22.3 kg/m. 2). The average follow-up was 9.9 years (range, 1–21). See Table1 The socket was placed at the level of the original acetabulum, and femoral shortening osteotomy was performed in 27 joints. Leg lengthening (LL) was defined the vertical distance from the tip of greater trochanter to the tear drop line. The mean LL was 3.1 cm (range, 1.5–6.7 cm). Clinical Harris hip score and sciatic nerve palsy was retrospectively assessed from the patients records. The correlation between LL, the percent LL (cm) divided by body height (cm) (%LL/BH) and the incidence of sciatic nerve palsy was investigated. Results. There were two sciatic nerve palsy (4.3%). These leg lengthening were 5.2 cm and 6.7 cm, respectively. These patients had complete recovery of neurological function. A significant correlation between the amount of LL and the incidence of sciatic nerve palsy was identified. LL more than 5 cm and %LL/BH â?§ 3.6 were significant risk factors of sciatic nerve palsy (p=0.0194, p=0.0028). See table2.3 Body mass index, preoperative hip flexion, previous operations were not associated with sciatic nerve palsy. Harris hip scores improved from a mean of 57.6 points prior to surgery to an average of 83.1 points at the latest follow-up. Kaplan- Meier survivorship analysis at 5 and 10 years revealed a cumulative survival rate of 94.1% and 64.2% respectively, with any implant revision as the end point. There were six cases of dislocations, which were successfully treated conservatively. Infection was not observed. Conclusions. Leg lengthening more than 5 cm and %LL/BH â?§ 3.6 were significant risk factors of sciatic nerve palsy

Introduction/Aim. Flexor tendon injuries of the hand are common with an incidence of over 3000 per annum in the UK. These injuries can affect hand function significantly. Early treatment with optimal repair is crucial to prevent disability. This study aimed at investigating the re-rupture rate following primary flexor tendon repair at our institution and to identify potential risk factors for re-rupture. Methods. 100 flexor tendons' injuries that underwent primary repair over a one-year period were reviewed retrospectively. Data was collected on age, gender, occupation, co morbidities, injured fingers, hand dominance, smoking status, zone of injury, time to surgery, surgeon grade, type of repair and suture, and antibiotic use on included patients. Causes of re-rupture were examined. We compared primary tendon repairs that had a re-rupture to those that did not re-rupture. Univariate and multivariate analysis was undertaken to identify the most significant risk factors for re-rupture. Results. 11 out of 100 (11%) repaired tendons went on to re-rupture. A significantly higher proportion of tendons re-rupture was noted when the repair was performed on the dominant hand (p-value = 0.009), in Zone 2 (0.001), and when a surgical delay of more than 72 hours from the time of injury occurred (0.01). Multivariate regression analysis identified repairs in Zone 2 to be the most significant predictor of re-rupture. Causes of re-rupture included infection in 5, rupture during rehabilitation exercises in 5 and fall in 1 patient. Conclusions. A re-rupture rate of 11% was noted in our study. Patients with Zone 2 injuries, repair on dominant hand and those with a surgical delay of more than 3 days were at higher risk of re-rupture. Careful consideration of these factors especially zone 2 injuries is crucial to reduce this rate. Providing a fast-track pathway for managing these patients can reduce time to surgery

To evaluate the proportion of microbial associations causing PJI, diversity of their strains and impact on treatment failure after the removal of the hip implant and insertion of a spacer. Spectrum of pathogens in 189 cases of PJI was studied retrospectively. Strains were isolated from the joint aspirates, tissue samples and removed orthopedic devices. The cohort comprised 144 cases of PJI after primary THA and 45 cases after the hip replacement revision surgery. All patients underwent first stage of two-stage revision procedure which involves the removal of a hip implant, debridement of infected periprosthetic tissues and subsequent insertion of a bone cement spacer. There were 92 males and 97 females (median age of 57 yrs). Statistical analysis of the results was performed with GraphPad Prism 6.0 (California, USA). Microbial associations were detected in 28.6% (n=54) of PJI cases. Gram-positive bacteria prevailed in both groups with mono- and polymicrobial etiology. There were 52.5% of S. aureus isolates in monomicrobial group and 25% isolates in polymicrobial group (p=0.0002). This also included 8.4 and 20.6% isolates of MRSA, respectively (p<0.0001). CNS were detected in 20.1% of mono- and 27.9% of polymicrobial infection isolates, including about 40% of MRSE in both groups. Gram-negative pathogens accounted for 25.7% of isolates in polymicrobial group and 14.1% in monomicrobial group (p=0.022). Non-fermenting bacteria prevailed among Gram-negative strains presented in associations. Acinetobacter sp. and P. aeruginosa were identified in 7.4% (p=0.043) and 5.1% (p=0.56) of polymicrobial isolates. The percentage of treatment failure after the removal of the hip implant and insertion of a spacer was considerably higher (p<0.0001) in patients with polymicrobial than monomicrobial infection: 72.2 vs 25.2%, respectively. The proportion of isolates in microbial associations involving Gram-negative pathogens was 61.5% in patients with infection recurrence and 26.7% in patients with a successful outcome of the surgery (p=0.033). Microbial associations were found in 28.6% of PJI cases after hip arthroplasty. They posed a significant risk for treatment failure after removal of the hip implant and insertion of a spacer. The multidrug-resistant strains (MRSA, Acinetobacter sp. and P. aeruginosa) were often isolated in microbial associations. Our results suggest that further study of the risk factors for polymicrobial infection is necessary in patients with PJI. Identification of a patient group at high risk for developing polymicrobial PJI will allow prescription of empiric antimicrobial therapy in time, taking into account possible multi-resistant pathogens

Introduction. Peak incidence of pulmonary embolism (PE) typically occurs weeks after total hip (THA) or knee (TKA) arthroplasty, long after hospital discharge. We investigated risk factors for acute PE occurring during index hospitalisation. Methods. Retrospective review of an IRB-approved database identified 329 arthroplasties performed by a single surgeon between 2002 and 2007 at two University teaching hospitals. Warfarin (goal INR 2.0) was standard venous thromboembolism prophylaxis. Results. There were 126 (38.6%) primary THA, 86 (26.1%) primary TKA and 117 (35.3%) revision arthroplasties. Seven patients (7/329; 2.1%) experienced clinically evident non-fatal pulmonary embolism, including 5 after TKA (5/128; 3.9%) and 2 after THA (2/194; 1.0%). In-hospital PE occurred in 4 (1.2%) patients (3 TKA, 1 THA) at a mean 2.7 days (range 2-4 days) after operation, compared with 3 symptomatic events (2 TKA, 1 THA) occurring after discharge (mean 19.3 days; range 8-27 days). Three of four patients suffering acute in-hospital PE were on pre-operative warfarin for chronic atrial fibrillation. Among all patients on pre-operative warfarin, 3 (12.5%) sustained an early PE, with a relative risk of 38.1 times that of controls not on chronic warfarin therapy (p=0.001). Body mass index greater than 30 kg/m2, a history of previous venous thromboembolism, coronary artery disease, ASA score, and type of operation were all found to not be associated with increased risk of in-hospital PE. Conclusion. Acute symptomatic in-hospital pulmonary embolism was correlated with chronic pre-operative warfarin anticoagulation. Compared to historical controls, time to PE was shorter in patients on chronic warfarin. Rebound hypercoagulability after discontinuation of chronic warfarin in preparation for total joint arthroplasty represents a greater hazard than excessive bleeding; we advocate bridging anticoagulation with LMWH in these patients

Aims

The primary aim of this study was to assess the independent association of the coronavirus disease 2019 (COVID-19) on postoperative mortality for patients undergoing orthopaedic and trauma surgery. The secondary aim was to identify factors that were associated with developing COVID-19 during the postoperative period.