Background. The rate of elderly people over 65 year-old increased from 18.5 % in 2004 to 26.0% in 2015 in Japan. Northern part of Japan is a head of the super-aging society, and the rate already reached 30.9% in 2015. Along with aging society, rapid increase of total hip arthroplasties (THA) has been predicted. The aim of this study is to estimate the trend of total hip arthroplasties in our super-aging area in Northern Japan. Methods. Trend on number and rate of THA in one of the local area of leading super-aging society were surveyed in the last decade using the database of diagnostic procedure and surgical records from 2004 to 2015. The cause of revision THA was analyzed in 2004–2009 versus in 2010–2015. Spearman's rank-correlation coefficient and student's t-tests were performed using the PASW 18 software (SPSS Institute Inc). Values of p < 0.05 were considered statistically significant. Results. The data revealed 24,822 cases of orthopaedic surgery, including 4,845 THA from 2004 to 2015. The reason for THA contained 3,343 osteoarthritis (OA, 69 %), 485 traumas (10 %), 291 loosening (6 %). THA increased from 282 cases in 2004 to 450 in 2015 year by year. They contained 3,905 cases of primary THA (81 %), 405 revision THA (8 %), and 535 bipolar hip arthroplasties (11 %). The revision contained 300 aseptic loosening (74 %), and 69 infections (17 %), and 36 dislocations (9%). The value of infections and dislocation as cause of revision THA was larger compared to the value of all revision THA between in 2004–2009 and in 2010–2015 (2.0 and 1.6 times). Discussion. The number and rate of THA increased year by year, because of expansion of elderly people affected by OA in the super-aging society. The number of revision THA due to infections or dislocation may be still increasing year by year

INTRODUCTION. This study is to determine the response of CRP after TKR surgery, both unilateral and simultaneous bilateral TKR. According to the previously published literature from North America and Europe CRP value peaks on the 1. st. and 2. nd. post-operative day and then gradually comes down to normal by 6–8 weeks post-operatively. AIM. To determine the trend of CRP in Indian patients undergoing TKR, both unilateral and simultaneous bilateral TKR. To see whether it follows the trend in North American and European population and to determine whether there is a difference in the CPR pattern in unilateral versus simultaneous bilateral TKR patients. MATERIAL & METHODS. Twenty six patients were included in this study. 13 patients each had unilateral TKR and simultaneous bilateral TKR. All the patients were operated by a single surgeon and assistant. Patients who had Rheumatoid arthritis and post operative adverse events like urinary tract infection were excluded from this study. All 26 patients were female patients and the mean age in the unilateral group was 67 years and in the simultaneous bilateral TKR group was 73 years. CRP levels were measured pre- operatively on 2. nd. day and 8 weeks. TKR was performed in a standard fashion. Both the groups received standard pre and post operative antibiotic prophylaxis. All patients received a posterior stabilized knee implant (Maxx Freedom Knee). RESULTS. In both the groups CRP level shot up on the 2. nd. post-operative day. Although the rise in CRP level was significantly higher in the simultaneous bilateral TKR group as against the unilateral TKR group. This difference was statistically significant. The CRP level came back to normal in about 39% of unilateral TKR patients at 8 weeks post operatively, while in majority (12 out of 13) of bilateral simultaneous TKR patient it was still elevated at 8 weeks post-op and had not come to normal. DISCUSSION. Macrophages are the important in the development of acute phase response namely CRP. The macrophages are present in the bone and bone marrow and less often in the skeletal muscle. The bone and bone marrow injury happening while performing TKR is responsible for elevation of CRP. Various North-American and European studies have shown that the CRP level increases significantly on the 1. st. postoperative day and the decreases from a peak on the 2. nd. postoperative day, attaining normal value at 6 to 8 weeks after operation. The result of our study are in variance to this published literature. Nearly 39% of our unilateral TKR patients and majority all of our simultaneous bilateral TKR patients did not achieve a normal CRP at 8 weeks after operation. These findings are significant as CRP is often used as a very sensitive indicator of post operative joint infection. Hence we conclude that the Indian TKR patients take longer time for the CRP values to become normal and the published literature regarding the normal levels of CRP in Unilateral TKR should not be extrapolated to simultaneous bilateral TKR group

Introduction. Spinal infections constitute a spectrum of disease comprising pyogenic, tuberculous, nonpyogenic-nontuberculous and postoperative spinal infections. The aim of this study was to review the epidemiology, diagnostic yield of first and second biopsy procedures and microbiology trends from Sheffield Spinal Infection Database along with analysing prognostic predictors in spinal infections. Materials & methods. Sheffield Spinal Infection Database collects data prospectively from regularly held Spinal infection MDTs. We accrued 125 spinal infections between September 2008 and October 2010. The medical records, blood results, radiology and bacteriology results of all patients identified were reviewed. In patients with negative first biopsy, second biopsy is contemplated and parenteral broad spectrum antibiotic treatment initiated. Results. There were 81 pyogenic, 16 tuberculous and 28 postoperative spinal infections. The mean age was 58.4 years (range, 19 to 88 years). There were 71 male and 54 female patients. There were 64 lumbar and 26 thoracic infections. Two level and multi-level spinal infections involving more than two segments occurred in 30 patients. Of sixty positive microbiology yields, the most common organism was methicillin sensitive staphylococcus aureus (n-23) followed by Streptococcal, E Coli and Coagulase negative staphylococcal and Pseudomonas infections. Second biopsy (done when first biopsy negative) was only positive in two patients. Conclusions. Annual incidence of de novo spinal infection was 48 (pyogenic-40, tuberculous-8). The most frequently isolated pathogen was Staphyloccus aureus. Multi-level infection, diabetic patients, resistant TB and postop infection in elderly patients constituted the ‘difficult to treat’ group in our experience. An algorithm for the diagnostic work-up and management of spinal infections is proposed

Introduction. Hip arthroscopy is a relatively new procedure and evidence to support its use remains limited. Well-designed prospective clinical trials with long-term outcomes are required, but study design requires an understanding of current practice. Our aim was to determine temporal trends in the uptake of non-arthroplasty hip surgery in England between 2001 and 2011. Methods. Using procedure and diagnosis codes, we interrogated the Hospital Episode Statistics (HES) Database for all hip procedures performed between 2001 and 2011, excluding those relating to arthroplasty, tumour or infection. Osteotomy procedures were also excluded. Results. Between 2001 and 2011, 12,684 joint-preserving hip procedures were recorded, of which 5,133 were performed open and 7,551 arthroscopically. The number of arthroscopic hip procedures performed each year increased by 631%, from 263 in 2001, to 1660 in 2011. The number of open procedures performed increased by 271%, from 260 in 2001, to 785 in 2011. The median age-group was 35–39 years of age and 60% of patients were female. There was considerable variation in procedure rates between different Strategic Health Authorities. In 2011, the greatest number of joint-preserving hip procedures were performed in the South West at 9.4 per 100,000 population, whereas the least were performed in the North East at 2.3 per 100,000 population. The proportion of procedures performed arthroscopically was highest in the North West at 75%, and lowest in the East Midlands at 44%. Conclusions. The number of joint-preserving hip procedures performed has risen significantly between 2001 and 2011, with an exponential rise in the number performed arthroscopically since 2006. Well-designed multi-centre clinical trials are essential to justify these relatively new procedures. If this growth continues, these procedures are likely to represent a significant commissioning burden in the future. HES data is limited since it does not include data from the Private Sector

Acute Compartment Syndrome (ACS) is an orthopaedic emergency that can develop after a wide array of etiologies. In this pilot study the MY01 device was used to assess its ease of use and its ability to continuously reflect the intracompartmental pressure (ICP) and transmit this data to a mobile device in real time. This preliminary data is from the lead site which is presently expanding data collection to five other sites as part of a multi-center study. Patients with long bone trauma of the lower or upper extremity posing a possibility of developing compartment syndrome were enrolled in the study. Informed consent was obtained from the patients. A Health Canada licensed continuous compartmental pressure monitor (MY01) was used to measure ICP. The device was inserted in the compartment that was deemed most likely to develop ACS and ICP was continuously measured for up to 18 hours. Fractures were classified according to the AO/OTA classification. Patient clinical signs and pain levels were recorded by healthcare staff during routine in-patient monitoring and were compared to the ICP from the device. Important treatment information was pulled from the patient's chart to help correlate all of the patient's data and symptoms. The study period was conducted from November 2020 through December 2021. Twenty-six patients were enrolled. There were 17 males, and nine females. The mean age was 38 years (range, 17–76). Seventeen patients received the device post-operatively and nine received it pre-operatively. Preliminary results show that post-operative ICPs tend to be significantly higher than pre-operative ICPs but tend to trend downwards very quickly. The trend in this measurement appears to be more significant than absolute numbers which is a real change from the previous literature. One patient pre-operatively illustrated a steep trend upwards with minimal clinical symptoms but required compartment release at the time of surgery that exhibited no muscle necrosis. The trend in this patient was very steep and, as predicted, predated the clinical findings of compartment syndrome. This trend allows an early warning signal of the absolute pressure, to come, in the compartment that is being assessed by the device. Preliminary results suggest that this device is reliable and relatively easy to use within our institutions. In addition it suggests that intracompartmental pressures can be higher immediately post-op but lower rapidly when the patient does not develop ACS. These results are in line with current literature of the difference between pre and post-operative baselines and thresholds of ICP, but are much more striking, as continuous measurements have not been part of the data set in most of past studies. Further elucidation of the pressure thresholds and profiles are currently being studied in the ongoing larger multicenter study and will add to our understanding of the critical values. This data, plus the added value of continuous trends in the pressure, upwards or downwards, will aid in preventing muscle necrosis during our management of these difficult long bone fractures

This study aimed to examine the changing trends in the reasons for total hip replacement (THR) revision surgery, in one country over a twenty-one year period, in order to assess whether changes in arthroplasty practices have impacted revision patterns and whether an awareness of these changes can be used to guide clinical practice and reduce future revision rates. The reason for revision THR performed between January 1999 and December 2019 was extracted from the New Zealand Joint Registry (NZJR). The results were then grouped into seven 3-year periods to allow for clearer visualization of trends. The reasons were compared across the seven time periods and trends in prosthesis use, patient age, gender, BMI and ASA grade were also reviewed. We compared the reasons for early revision, within one year, with the overall revision rates. There were 20,740 revision THR registered of which 7665 were revisions of hips with the index procedure registered during the 21 year period. There has been a statistically significant increase in both femoral fracture (4.1 – 14.9%, p<0.001) and pain (8.1 – 14.9%, p<0.001) as a reason for hip revision. While dislocation has significantly decreased from 57.6% to 17.1% (p<0.001). Deep infection decreased over the first 15 years but has subsequently seen further increases over the last 6 years. Conversely both femoral and acetabular loosening increased over the first 12 years but have subsequently decreased over the last 9 years. The rate of early revisions rose from 0.86% to 1.30% of all revision procedures, with a significant rise in revision for deep infection (13-33% of all causes, p<0.001) and femoral fracture (4-18%, p<0.001), whereas revision for dislocation decreased (59-30%, p<0.001). Adjusting for age and gender femoral fracture and deep infection rates remained significant for both (p<0.05). Adjusting for age, gender and ASA was only significant for infection. The most troubling finding was the increased rate of deep infection in revision THR, with no obvious linked pattern, whereas, the reduction in revision for dislocation, aseptic femoral and acetabular loosening can be linked to the changing patterns of the use of larger femoral heads and improved bearing surfaces

The aim of this study was to determine the incidence, annual trend, perioperative outcomes, and identify risk factors of early-onset (≤ 90 days) deep surgical site infection (SSI) following primary total knee arthroplasty (TKA) for osteoarthritis. Risk factors for early-onset deep SSI were assessed. We performed a retrospective population-based cohort study using prospectively collected patient-level data from several provincial administrative data repositories between January 2013, and March 2020. The diagnosis of early-onset deep SSI was based on published Centre for Disease Control/National Healthcare Safety Network (CDC/NHSN) definitions. The Mann-Kendall Trend Test was used to detect monotonic trends in early-onset deep SSI rates over time. The effects of various patient and surgical risk factors for early-onset deep SSI were analyzed using multiple logistic regression. Secondary outcomes were 90-day mortality and 90-day readmission. A total of 20,580 patients underwent primary TKA for osteoarthritis. Forty patients had a confirmed deep SSI within 90-days of surgery representing a cumulative incidence of 0.19%. The annual infection rate did not change over the 7-year study period (p = 0.879). Risk factors associated with early-onset deep SSI included blood transfusions (OR, 3.93 [95% CI 1.34-9.20]; p=0.004), drug or alcohol abuse (OR, 4.91 [95% CI 1.85-10.93]; p<0.001), and surgeon volume less than 30 TKA per year (OR, 4.45 [1.07-12.43]; p=0.013). Early-onset deep SSI was not associated with 90-days mortality (OR, 11.68 [0.09-90-58]; p=0.217), but was associated with an increased chance of 90-day readmission (OR, 50.78 [26.47-102.02]; p<0.001). This study establishes a reliable baseline infection rate for early-onset deep SSI after TKA for osteoarthritis through the use of a robust methodological process. Several risk factors for early-onset deep SSI are potentially modifiable or can be optimized prior to surgery and be effective in reducing the incidence of early-onset SSI. This could guide the formulation of provincial screening programs and identify patients at high risk for SSI

Aim. Prosthetic joint infection (PJI) is a devastating complication of joint replacement, having an impact on morbimortality but also on national health systems and their budgets. The current situation of PJI-related hospitalizations in Spain and their changes over time are unknown. Therefore, we aimed to analyze the hospitalization burden of PJI, including costs and trends in recent decades. Methods. Retrospective observational study including data from the National Surveillance System for Hospital Data, which includes more than 98% of Spanish hospitals. During the period 2000–2015, hospitalizations due to PJI (ICD-9-CM 996.66) as main diagnosis were included. Epidemiological trends were evaluated during four periods: P1, 2000–2003; P2, 2004–2007; P3, 2008–2011; P4, 2012–2015. Annual hospitalization rates per 100,000 inhabitants and trends were also calculated. Results. Among 5,721,6725 hospitalizations, 49,835 were PJI related, which represented 8.71/10,000 admissions. We observed a significant increase in the number of PJI-related hospitalizations per 10,000 admissions during the study period: 6.43 P1, 8.53 P2, 9.60 P3, 10.05 P4 (p<0.001). The annual hospitalization rate was 6.9/100,000 inhabitants (95%CI 6.9–7), which also increased over time (p<0.001). The median age was 72 years (IQR 65–78) and 58.12% were women. Hospitalization rates were higher in women (7.95 vs 5.90; p<0.001) and also increased with patients’ age (p<0.001). Whereas the median length of stay was 7 days (IQR 7–8) in the global cohort, it was 18 days (IQR 10–31) in those with PJI-related hospitalization; however, the median length of stay in PJI-related hospitalizations decreased during the study period (P1 20 days, P4 16 days, p<0.001). The total cost for the healthcare system was 366 million euros and the median cost per patient was 6937 euros (IQR 3584–10505), which significantly increased from 4804 euros in P1 to 8534 in P4 (p<0.001). The majority of patients (90.32%) were discharged home and the case-fatality rate was 2.70%, without significant differences during the study (p=0.384). Conclusions. In Spain, PJI-related hospitalizations have increased in recent decades, with higher costs despite the decrease in length of stay. PJI is a first magnitude healthcare problem, which should be prioritized in health systems and budgets

The demand for revision total knee arthroplasty (TKA) has grown significantly in recent years. The two major fixation methods for stems in revision TKA include cemented and ‘hybrid’ fixation. We explore the optimal fixation method using data from recent, well-designed comparative studies. We performed a systematic review of comparative studies published within the last 10 years with a minimum follow-up of 24 months. To allow for missing data, a random-effects meta-analysis of all available cases was performed. The odds ratio (OR) for the relevant outcome was calculated with 95% confidence intervals. The effects of small studies were analyzed using a funnel plot, and asymmetry was assessed using Egger's test. The primary outcome measure was all-cause failure. Secondary outcome measures included all-cause revision, aseptic revision and radiographic failure. There was a significantly lower failure rate for hybrid stems when compared to cemented stems (p = 0.006) (OR 0.61, 95% CI 0.42-0.87). Heterogeneity was 4.3% and insignificant (p = 0.39). There was a trend toward superior hybrid performance for all other outcome measures including all-cause re-revision, aseptic re-revision and radiographic failure. Recent evidence suggests a significantly lower failure rate for hybrid stems in revision TKA. There is also a trend favoring the use of hybrid stems for all outcome variables assessed in this study. This is the first time a significant difference in outcome has been demonstrated through systematic review of these two modes of stem fixation. We therefore recommend the use, where possible, of hybrid stems in revision TKA

The NZ Standards of Service Provision for Sarcoma patients were developed by the NZ Sarcoma working group and published by the Ministry of Health (MOH) in 2013. Although not formally enacted by the MOH we aimed to determine the impact of these published standards and referral pathways on disease-specific survival of patients with soft-tissue sarcoma in NZ. The Middlemore Musculoskeletal Tumour Unit database was searched. Patients referred for treatment in our centre with a diagnosis of soft tissue sarcoma in the five-year period before (n=115) and after (n=155) were included. We excluded patients with bone sarcomas and retroperitoneal soft tissue sarcomas. The rate of referral after inappropriate treatment reduced after implementation of the Standards (24% vs 12%, p=0.010). The number of patients referred with tumours larger than 50mm decreased (74.8% vs 72.3%, p=0.021) and fewer had metastases at diagnosis (11.3% vs 3.2%, p=0.017). Mortality was lower in the group after introduction of the Standards (45% vs 30%, p=0.017). The estimated disease-specific survival curve between the two groups shows a trend towards increased survival in the post-standards group, although not reaching statistical significance. Local recurrence rate and metastasis rate after definitive treatment were similar between the two groups. Patients had a shorter duration of symptoms before referral in the post-Standards group although this was not statistically significant. Since implementation of the Standards, patients have been referred more promptly, with fewer inappropriate treatments. The time to mortality curve indicates a trend towards improved disease-specific survival. We conclude that the pathway for investigation and referral for this condition has become clearer, supporting the ongoing use of the Sarcoma Standards, and that these should be formally implemented by the MOH

Proximal humerus fractures (PHF) are common, accounting for approximately 5% of all fractures. Approximately 30% require surgical intervention which can range from open reduction with internal fixation (ORIF) to shoulder arthroplasty (including hemiarthroplasty, total shoulder arthroplasty, (TSA) or reverse total shoulder arthroplasty (RTSA)). The aim of this study was to assess trends in operative interventions for PHF in an Australian population. Data was retrospectively collected for patients diagnosed with a PHF and requiring surgical intervention between January 2001 and December 2020. Data for patients undergoing ORIF were extracted from the Medicare database, while data for patients receiving arthroplasty for PHF were obtained from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). Across the study period, ORIF was the most common surgical procedure for management of PHFs. However, since 2019, RTSA has surpassed ORIF as the most common surgical procedure to treat PHFs, accounting for 51% of operations. While the number of RTSA procedures for PHF has increased, ORIF and shoulder hemiarthroplasty has significantly reduced since 2007 (p < 0.001). TSA has remained uncommon across the follow-up period, accounting for less than 1% of all operations. Patients younger than 65 years were more likely to receive ORIF, while those aged 65 years or greater were more likely to receive hemiarthroplasty or RTSA. While the number of ORIF procedures has increased during the period of interest, it has diminished as a proportion of overall procedure volume. RTSA is becoming increasingly popular, with decreasing utilization of hemiarthroplasty, and TSA for fracture remaining uncommon. These trends provide information that can be used to guide resource allocation and health provision in the future. A comparison to similar data from other nations would be useful

Abstract. Introduction. The management of hip fractures has advanced on all aspects from prevention, specialised hip fracture units, early operative intervention and rehabilitation in line with increasing incidence in an aging population. Accurate data analysis on the incidence and trends of hip fractures is imperative to guide future management planning. Methods. A review of all articles published on mortality after hip fracture over a twenty year period (1999–2018) was undertaken to determine any changes that had occurred in the demographics and mortality over this period. This article complements and expands upon the findings of a previous article by the authors assessing a four decade period (1959 – 1998) and attempts to present trends and geographical variations over sixty years. Results. The mean age of patients sustaining hip fractures has increased from 73 years (1960s) to 81 years (2000s) to 82 years (2010s). Over the six decade period one-year mortality has reduced from 27% (1960s) to 20% (2010s). The proportion of female hip fractures has decreased from 84% (1960s) to 70% in 2010s. Intracapsular fractures have drecreased from 54% (1970s) to 49% (2000s) and 48% (2010s). Conclusion. Our study indicates that progress has been made with preventative planning, medical management, specialised orthogeriatric units and surgical expediency all playing a role in the improvements in mean age of hip fracture and reduction in mortality rates. While geographical variations do still exist there has been an increase in the study of hip fractures globally indicating increased attention and commitment to an

Aim. To evaluate the bacterial counts of sonicatied implants in patients with osteoarticular infections. Various studies have demostrated the usefulness of sonication of retrieved implants in order to provide an accurate microbiological diagnosis. Although cutoff values for original sonicate counts have been established, the use of centrifugation may influence these values. Method. A retrospective, single-center study, including sonication fluid samples from implants removed between January 2011 and October 2023, was performed. Patients were diagnosed with implant-associated infection based on the criteria available at the time of diagnosis. Osteoarticular implants were sonicated following the protocol described by Esteban et al. Sonicated fluid was centrifuged for 20 minutes at 3000 x g, and the sediment was resuspended in 5 mL of phosphate buffer solution. Ten µl of the sample were streaked onto each medium for quantitative culture. Bacterial counts exceeding 100,000 CFU/mL were considered as 100,000 CFU/mL for statistical analysis. Results. The study included 457 sonication fluid samples. Of these, 316 samples were from patients with prosthetic joint infection (PJI), with 26.3 % diagnosed with acute PJI and 73.7 % with chronic PJI. Additionally, 141 samples were from patients with osteosynthesis infection. The median CFU/ml in the sonication fluid was 40,000 CFU/mL (IQR 1,000 CFU/mL-100,000 CFU/mL). No statistically significant difference was observed between the different types of implants (prosthesis vs. osteosynthesis, p=0.218). A trend of higher counts was noted for acute PJI compared to chronic PJI (р=0.052). Most infections were monomicrobial, but 16.2% were polymicrobial. Statistically significant higher bacterial counts were observed in polymicrobial infections compared to monomicrobial infections (р<0.005). Among monomicrobial infections, no differences were found between Gram-negative and Gram-positive microorganisms (р=0.416). No differences were also found between joints (knee vs. hip) (p=0.353). Conclusions. Significant variability was observed in the number of colonies detected in all samples, regardless of the type of implant, the number of microorganisms or the species identified. Higher counts were detected in polymicrobial infections, and a trend was also noted for higher counts in acute infections

Canada is second only to the United States worldwide in the number of opioid prescriptions per capita. Despite this, little is known about prescription patterns for patients undergoing total joint arthroplasty (TJA). The purpose of this study was to detail preoperative opioid use patterns and investigate the effect it has on perioperative quality outcomes in patients undergoing elective total hip and total knee arthroplasty surgery (THA and TKA). The study cohort was constructed from hospital Discharge Abstract Data (DAD) and National Ambulatory Care Reporting System (NACRS) data, using Canadian Classification of Health Intervention codes to select all primary THA and TKA procedures from 2017-2020 in Nova Scotia. Opioid use was defined as any prescription filled at discharge as identified in the Nova Scotia Drug Information System (DIS). Emergency Department (ED) and Family Doctor (FD) visits for pain were ascertained from Physician Claims data. Multivariate logistic regression was used to test for associations controlling for confounders. Chi-squared statistics at 95% confidence level used to test for statistical significance. In total, 14,819 TJA patients were analysed and 4306 patients (29.0%) had at least one opioid prescription in the year prior to surgery. Overall, there was no significant difference noted in preoperative opiate use between patients undergoing TKA vs THA (28.8% vs 29.4%). During the period 2017-2019 we observed a declining year-on-year trend in preoperative opiate use. Interestingly, this trend failed to continue into 2020, where preoperative opiate use was observed to increase by 15% and exceeded 2017 levels. Within the first 90 days of discharge, 22.9% of TKA and 20.9% of THA patients presented to the ED or their FD with pain related issues. Preoperative opiate use was found to be a statistically significant predictor for these presentations (TKA: odds ratio [OR], 1.45; 95% confidence interval [CI], 1.29 to 1.62; THA: OR, 1.46; 95% CI, 1.28 to 1.65). Preoperative opioid consumption in TJA remains high, and is independently associated with a higher risk of 90 day return to the FD or ED. The widespread dissemination of opioid reduction strategies introduced during the middle of the last decade may have reduced preoperative opiate utilisation. Access barriers and practice changes due to the COVID-19 pandemic may now have annulled this effect

There is limited literature on the effects of socioeconomic factors on outcomes after total ankle arthroplasty (TAA). In the setting of hip or knee arthroplasty, patients of a lower socioeconomic status demonstrate poorer post-operative satisfaction, longer lengths of stay, and larger functional limitations. It is important to ascertain whether this phenomenon is present in ankle arthritis patients. This is the first study to address the weight of potential socioeconomic factors in affecting various socioeconomic classes, in terms of how they benefit from ankle arthroplasty. This is retrospective cohort study of 447 patients who underwent a TAA. Primary outcomes included pre-operative and final follow-up AAOS pain, AAOS disability, and SF-36 scores. We then used postal codes to determine median household income using Canadian 2015 census data. Incomes were divided into five groups based on equal amounts over the range of incomes. This method has been used to study medical conditions such as COPD and cardiac disease. These income groups were then compared for differences in outcome measures. Statistical analysis was done using unpaired t-test. A total of 447 patients were divided into quintiles by income. From lowest income to highest income, the groups had 54, 207, 86, 64, and 36 patients, respectively. The average time from surgery to final follow up was 85.6 months. Interestingly, we found that patients within the middle household income groups had significantly lower AAOS disability scores compared to the lowest income groups at final follow-up (26.41 vs 35.70, p=0.035). Furthermore, there was a trend towards middle income households and lower post-operative AAOS pain scores compared to the lowest income group (19.57 vs 26.65, p=0.063). There was also a trend toward poorer AAOS disability scores when comparing middle income groups to high income groups post-operatively (26.41 vs 32.27, p=0.058). Pre-operatively, patients within the middle-income group had more pain, compared to the lowest and the highest income groups. No significant differences in SF-36 scores were observed. There were no significant differences seen in middle income groups compared to the highest income group for AAOS pain post-operatively. There were no significant differences found in pre-operative AAOS disability score between income groups. Patients from middle income groups who have undergone TAA demonstrate poorer function and possibly more pain, compared to lower and higher income groups. This suggests that TAA is a viable option for lower socioeconomic groups and should not be a source of discouragement for surgeons. In this circumstance there is no real disparity between the rich and the poor. Further investigation is needed to explore reasons for diminished performance in middle class patients

Prolonged bedrest in hospitalized patients is a major risk factor for venous thromboembolism (VTE), especially in high risk patients with hip fracture. Thrombelastography (TEG) is a whole blood viscoelastic hemostatic assay with evidence that an elevated maximal amplitude (MA), a measure of clot strength, is predictive of VTE in orthopaedic trauma patients. The objective of this study was to compare the TEG MA parameter between patients with hip fracture who were more mobile post-operatively and discharged from hospital early to patients with hip fracture with reduced mobility and prolonged hospitalizations post-operatively. In this prospective cohort study, TEG analysis was performed in patients with hip fracture every 24-hours from admission until post-operative day (POD) 5, then at 2- and 6-weeks post-operatively. Hypercoagulability was defined by MA > 65. Patients were divided into an early (within 5-day) and late (after 5-day) discharge group, inpatient at 2-weeks group, and discharge to MSK rehabilitation (MSK rehab), and long term care (LTC) groups. Two-sample t-test was used to analyze differences in MA between the early discharge and less mobile groups. All statistical tests were two-sided, and p-values < 0.05 were considered statistically significant. In total, 121 patients with a median age of 81.0 were included. Patients in the early discharge group (n=15) were younger (median age 64.0) and more likely to ambulate without gait aids pre-injury (86.7%) compared to patients in the late discharge group (n=105), inpatients at 2-weeks (n=48), discharged to MSK rehab (n=30), and LTC (n=20). At two weeks post-operative, the early discharge group was significantly less hypercoagulable (MA=68.9, SD 3.0) compared to patients in the other four groups. At 6-weeks post-operative, the early discharge group was the only group to demonstrate a trend towards mean MA below the MA > 65 hypercoagulable threshold (MA=64.4, p=0.45). Symptomatic VTE events were detected in three patients (2.5%) post-operatively. All three patients had hospitalizations longer than five days after surgery. In conclusion, our analysis of hypercoagulability secondary to reduced post-operative mobility demonstrates that patients with hip fracture who were able to mobilize independently sooner after hip fracture surgery, have a reduced peak hypercoagulable state. In addition, there is a trend towards earlier return to normal coagulation status as determined by the TEG MA parameter. Post-operative mobility status may play a role in determining individualized duration of thromboprophylaxis following hip fracture surgery. Future studies comparing TEG to clinically validated mobility tools may more closely evaluate the contribution of venous stasis due to reduced mobility on hypercoagulation following hip fracture surgery

Prolonged bedrest in hospitalized patients is a major risk factor for venous thromboembolism (VTE), especially in high risk patients with hip fracture. Thrombelastography (TEG) is a whole blood viscoelastic hemostatic assay with evidence that an elevated maximal amplitude (MA), a measure of clot strength, is predictive of VTE in orthopaedic trauma patients. The objective of this study was to compare the TEG MA parameter between patients with hip fracture who were more mobile post-operatively and discharged from hospital early to patients with hip fracture with reduced mobility and prolonged hospitalizations post-operatively. In this prospective cohort study, TEG analysis was performed in patients with hip fracture every 24-hours from admission until post-operative day (POD) 5, then at 2- and 6-weeks post-operatively. Hypercoagulability was defined by MA > 65. Patients were divided into an early (within 5-day) and late (after 5-day) discharge group, inpatient at 2-weeks group, and discharge to MSK rehabilitation (MSK rehab), and long term care (LTC) groups. Two-sample t-test was used to analyze differences in MA between the early discharge and less mobile groups. All statistical tests were two-sided, and p-values < 0.05 were considered statistically significant. In total, 121 patients with a median age of 81.0 were included. Patients in the early discharge group (n=15) were younger (median age 64.0) and more likely to ambulate without gait aids pre-injury (86.7%) compared to patients in the late discharge group (n=105), inpatients at 2-weeks (n=48), discharged to MSK rehab (n=30), and LTC (n=20). At two weeks post-operative, the early discharge group was significantly less hypercoagulable (MA=68.9, SD 3.0) compared to patients in the other four groups. At 6-weeks post-operative, the early discharge group was the only group to demonstrate a trend towards mean MA below the MA > 65 hypercoagulable threshold (MA=64.4, p=0.45). Symptomatic VTE events were detected in three patients (2.5%) post-operatively. All three patients had hospitalizations longer than five days after surgery. In conclusion, our analysis of hypercoagulability secondary to reduced post-operative mobility demonstrates that patients with hip fracture who were able to mobilize independently sooner after hip fracture surgery, have a reduced peak hypercoagulable state. In addition, there is a trend towards earlier return to normal coagulation status as determined by the TEG MA parameter. Post-operative mobility status may play a role in determining individualized duration of thromboprophylaxis following hip fracture surgery. Future studies comparing TEG to clinically validated mobility tools may more closely evaluate the contribution of venous stasis due to reduced mobility on hypercoagulation following hip fracture surgery

To describe the longitudinal trends in patients with obesity and Metabolic Syndrome (MetS) undergoing TKA and the associated impact on complications and lengths of hospital stay. We identified patients who underwent primary TKA between 2006 – 2017 within the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. We recorded patient demographics, length of stay (LOS), and 30-day major and minor complications. We labelled those with an obese Body Mass Index (BMI ≥ 30), hypertension, and diabetes as having MetS. We evaluated mean BMI, LOS, and 30-day complication rates in all patients, obese patients, and those with MetS from 2006-2017. We used multivariable regression to evaluate the trends in BMI, complications, and LOS over time in all patients and those with MetS, and the effect of BMI and MetS on complication rates and LOS, stratified by year. 270,846 patients underwent primary TKA at hospitals participating in the NSQIP database. 63.71% of patients were obese (n = 172,333), 15.21% were morbidly obese (n = 41,130), and 12.37% met criteria for MetS (n = 33,470). Mean BMI in TKA patients increased at a rate of 0.03 per year (0.02-0.05; p < 0 .0001). Despite this, the rate of adverse events in obese patients decreased: major complications by an odds ratio (OR) of 0.94 (0.93-0.96; p < 0 .0001) and minor complications by 0.94 (0.93-0.95; p < 0 .001). LOS also decreased over time at an average rate of −0.058 days per year (-0.059 to −0.057; p < 0 .0001). The proportion of patients with MetS did not increase, however similar improvements in major complications (OR 0.94 [0.91-0.97] p < 0 .0001), minor complications (OR 0.97 [0.94-1.00]; p < 0 .0330), and LOS (mean −0.055 [-0.056 to −0.054] p < 0 .0001) were found. In morbidly obese patients (BMI ≥ 40), there was a decreased proportion per year (OR 0.989 [0.98-0.994] p < 0 .0001). Factors specifically associated with major complications in obese patients included COPD (OR 1.75 [1.55-2.00] p < 0.0001) and diabetes (OR 1.10 [1.02-1.1] p = 0.017). Hypertension (OR 1.12 [1.03-1.21] p = 0.0079) was associated with minor complications. Similarly, in patients with MetS, major complications were associated with COPD (OR 1.72 [1.35-2.18] p < 0.0001). Neuraxial anesthesia was associated with a lower risk for major complications in the obese cohort (OR 0.87 [0.81-0.92] p < 0.0001). BMI ≥ 40 was associated with a greater risk for minor complications (OR 1.37 [1.26-1.50] p < 0.0001), major complications (1.11 [1.02-1.21] p = 0.015), and increased LOS (+0.08 days [0.07-0.09] p < 0.0001). Mean BMI in patients undergoing primary TKA increased from 2006 - 2017. MetS comorbidities such as diabetes and hypertension elevated the risk for complications in obese patients. COPD contributed to higher rates of major complications. The obesity-specific risk reduction with spinal anesthesia suggests an improved post-anesthetic clinical course in obese patients with pre-existing pulmonary pathology. Encouragingly, the overall rates of complications and LOS in patients with obesity and MetS exhibited a longitudinal decline. This finding may be related to the decreased proportion of patients with BMI ≥ 40 treated over the same period, possibly the result of quality improvement initiatives aimed at delaying high-risk surgery in morbidly obese patients until healthy weight loss is achieved. These findings may also reflect increased awareness and improved management of these patients and their elevated risk profiles

Introduction. Innovations in orthopaedic technology and infrastructure growth often require significant funding. Although an increasing trend has been observed for third-party investments into medical startups and physician practices, no study has examined the role of this funding in orthopaedics, including the influence of venture capital (VC). Therefore, this study analyzed trends in VC investments related to the field of orthopaedic surgery, as well as the characteristics of companies receiving said investments. Methods. Venture capital investments into orthopaedic-related businesses were reviewed from 2000–2019 using Capital IQ, a proprietary market intelligence platform documenting financial transactions. The dataset was initially filtered to include healthcare-related venture capital transactions pertaining to the field of orthopaedic surgery. The final list of VC investments and their corresponding businesses were categorized by transaction year, amount (in USD), and orthopaedic subspecialty. The number and sum of VC investments was calculated both annually and cumulatively across the entire study period. Linear regression was used for trend analysis within two distinct, decade-long timeframes (2000–2009 and 2010–2019) and one-way analysis of variance was used to assess differences across orthopaedic subspecialties. Results. Over the course of two decades, 672 VC investments were made into orthopaedic-related businesses, representing a total of $3.5 billion. Both the number and dollar value of transactions were greater in the second decade (2010–19) (233, $1.9 billion), compared to the first decade (439, $1.6 billion). Linear regression revealed significant trends in both the quantity and dollar amount of VC transactions within the decade from 2000–09 (p = 0.0002 and p = 0.0143, respectively) but no such trend in the latter decade (Figure 1A-B, Figure 2A-B). Throughout both decades studied, the largest and most frequent VC investments took place within Spine and Adult Reconstruction (Figure 3). One-way analysis of variance revealed significant differences in the annual frequency and amount of investment across orthopaedic subspecialties (p < 0.001 and p < 0.001, respectively). Discussion and Conclusion. The present data suggest that an initially rising trend in VC investment in orthopaedic-related businesses may have plateaued over the past decade. These findings may have important implications for continued investment into orthopaedic innovations and collaboration between the surgical community and private sector, as well as the perceived profitability of orthopaedic industries by third-party interests. For any figures or tables, please contact the authors directly

Introduction. Flexor sheath infections require prompt diagnosis, and management with intravenous antibiotics and/or surgical washout followed by physiotherapy. Complication rates as high as 38% have been reported. Methods. A retrospective review was carried out of all patients between January 2014 and May 2021 attending with a suspected or confirmed diagnosis of flexor sheath infection. Age, gender, co-morbidities, cause of infection, management, and subsequent complications recorded. Results. Of 132 patients, 67% were male. Mean age was 50.8 years. A trend towards fewer presentations each year with animal bites, foreign bodies and penetrating trauma as the main cause of infection. 89% (n=117) required admission, 77% (n=101) underwent a surgical washout. 11% (n=15) were treated as an outpatient. 7% (n=9) suffered a complication. Discussion. Whilst flexor sheath washout continues to be the treatment of choice, 23% of patients were managed with intravenous antibiotics, 48% of these purely via an outpatient service. Our overall complication rate was 7%