Comparison of acute outcomes from elective total hip replacements and after fragility femoral neck fractures in nonagenarians.

BACKGROUND: Hip hemiarthroplasty has traditionally been used to treat displaced femoral neck fractures in older, frailer patients whilst total hip replacements (THR) have been reserved for younger and fitter patients. However, not all elderly patients are frail, and some may be able to tolerate and benefit from an acute THR. Nonagenarians are a particularly heterogenous subpopulation of the elderly, with varying degrees of independence. Since THRs are performed electively as a routine treatment for osteoarthritis in the elderly, its safety is well established in the older patient. The aim of this study was to compare the safety of emergency THR to elective THR in nonagenarians. METHODS: A retrospective 10-year cohort study was conducted using data submitted to the National Hip Fracture Database (NHFD) across three hospitals in one large NHS Trust. Data was collected from 126 nonagenarians who underwent THRs between 1st January 2010 - 31st December 2020 and was categorised into emergency THR and elective THR groups. Mortality rates were compared between the two groups. Secondary outcomes were also compared including postoperative complications (dislocations, revision surgeries, and periprosthetic fracture), length of stay in hospital, and discharge destination. RESULTS: There was no significant difference in mortality between the two groups, with 1-year mortality rates of 11.4% and 12.1% reported for emergency and elective patients respectively (p = 0.848). There were no significant differences in postoperative complication rate and discharge destination. Patients who had emergency THR spent 5.56 days longer in hospital compared to elective patients (p = 0.015). CONCLUSION: There is no increased risk of 1-year mortality in emergency THR compared to elective THR, in a nonagenarian population. Therefore, nonagenarians presenting with a hip fracture who would have been considered for a THR if presenting on an elective basis should not be precluded from an emergency THR on safety grounds. TRIAL REGISTRATION: Not necessary as this was deemed not to be clinical research, and was considered to be a service evaluation.

Modelling of longitudinally cut carrot curling induced by the vascular cylinder-cortex interference pressure.

Cut carrot pieces are popular convenience foods, which enable the use of misshapen or physiologically imperfect produce. Cut carrots curl due to residual stress, which limits their shelf life and causes unnecessary food waste. The aim of this study is to identify the geometrical and environmental factors which have the most influence on their longevity. An analytical equation was developed using compound cylinder solutions, and this was used to define carrot-specific finite element (FE) models. Over 100 longitudinally cut Lancashire Nantes carrot halves were characterized, each was modelled analytically and verified using FE models. This model was evaluated by comparing predicted curvatures to ones experimentally measured over a week. The average radius of curvature decreased from 1.61 to 1.1 m a week after. A 1.32× reduction in the elastic modulus after 7 days was observed. The moisture content reduction relates to 22% weight loss, correlating to the decreasing radius of curvature. Subsequently, carrots are recommended to be stored in humidity-controlled environments. The experimental results from this study match the predictions made using mechanical principles. The research provides a methodology to predict the deformation of cut root vegetables, and the procedure is likely to be applicable to other plant structures.

Predicting 30-day mortality after hip fracture: the G4A calibrated prognostic tool.

INTRODUCTION: Proximal femoral fracture is common with a high mortality (7% mortality at 30 days). Accurate determination of mortality risk allows better consenting, clinical management and expectation management. Our study aim was to develop a prognostic tool to predict 30-day mortality after proximal femoral fracture, among patients treated within a dedicated hip fracture unit. MATERIALS AND METHODS: We collected data from our hospital concerning 2210 patients with 2287 proximal femoral fractures. The clinical parameters of 97 patients who died within 30 days of surgery were analysed. We used logistic regression to determine if the parameters' relationship with 30-day mortality was statistically significant or not. The statistically significant parameters were used to create a prognostic model for predicting 30-day mortality. RESULTS: The 5 independent predictors of 30-day mortality were gender, age, admission source, preoperative Abbreviated Mental Test Score (AMTS) and American Society of Anesthesiologists Score (ASA). The highest risk was for males >85 years, admitted from institutional care, with low preoperative mental test score and high ASA grade. Using these predictors, we formulated the G4A score. The Hosmer-Lemeshow 'goodness of fit' test showed good concordance between observed and predicted mortality rates. CONCLUSIONS: We recommend the use of the G4A score to predict 30-day mortality after surgery for proximal femoral fracture, particularly within dedicated hip fracture units. Further research is needed to establish whether the findings of this study are applicable on a national scale.

Thompson Hemiarthroplasty for Femoral Neck Fracture Is Associated With Increased Risk of Dislocation.

BACKGROUND: This contemporaneous large multicenter retrospective study reflective of current practice, assesses the impact of patient factors, prosthesis selection, and implant features on the risk of dislocation after hip hemiarthroplasty for femoral neck fracture. METHODS: Radiographic records for 4116 consecutive patients who underwent a hip hemiarthroplasty between January 1, 2009 and September 30, 2017 at 3 acute hospitals (including a regional major trauma center) for a neck of femur fracture were reviewed in conjunction with United Kingdom National Hip Fracture Database records. RESULTS: In total, 4116 patients were eligible for inclusion in the study; 63 of 4116 (1.5%) dislocations were identified. Patient age, gender, preoperative abbreviated mental test score, postoperative abbreviated mental test score, and American Society of Anaesthesiologists grade were not found to be significant predictors of dislocation rates (P < .05). The Furlong prosthesis was the most commonly used implant (2280/4116, 55.4%) followed by the Exeter V40 + Unitrax head (1179/4116, 28.6%), other implants used during the study period were the monoblock Austin-Moore and Thompson implants. Hemiarthroplasty operations undertaken with the Thompson (24/273, 3.7%) were found to have significantly higher dislocation rates (P < .05). Cemented vs uncemented, variable vs fixed offset, and monoblock vs modular implant designs did not contribute to higher dislocation rates (P < .05). Surgeon seniority was also not a significant risk factor for subsequent dislocation (P < .05). CONCLUSIONS: Thompson hip hemiarthroplasties are associated with higher dislocation rates when compared to a contemporaneous cohort of implant choices and considerations for their use should be made in conjunction with this major risk factor for the need for subsequent operations.

Understanding survival analysis: actuarial life tables and the Kaplan-Meier plot.

Survival analysis is a set of methods used to study the time between enrollment in a study and the occurrence of an event of interest. Two methods are commonly used: actuarial life tables and the Kaplan-Meier approach for survival analysis. A good understanding of both these methods is useful when reading and appraising the literature concerning prognostic and interventional studies. Kaplan-Meier curves are widely used as they enable analysis of incomplete sets of data (i.e. after patients withdraw from studies or are lost to follow up). This review explains these two methods and gives practical examples of their use.

Understanding and interpreting funnel plots for the clinician.

Funnel plots are an increasingly common graphical tool which are widely used in the literature. They were first introduced by Light and Pillemer in 1984 . In scientific literature, funnel plots are used to identify the probability of bias in meta-analyses and compare institutional performance. The ability to identify variation is better with graphical than tabular display. In addition, the way data are presented can directly influence the interpretation of results. This was demonstrated by Marshall et al (2004) , who presented institutional mortality data in both a league table and control chart format. This study illustrated that when displayed as a league table, a greater number of units were identified for investigation than were actually required. The use of control charts or funnel plots may therefore show benefit in reducing the number of inappropriately labelled outliers. This article explains how clinicians should read and interpret funnel plots, and discusses their considerations and limitations.

Blunt chest trauma: bony injury in the thorax.

The management of blunt chest trauma is an evolving concept with no clear current guidelines. This article explores the bony injuries associated with this, focusing on rib fractures and flail segments and the themes around investigation and best management.

Blunt chest trauma: soft tissue injury in the thorax.

The management of blunt chest trauma is evolving. This article discusses the soft tissue injuries associated with blunt chest trauma.

Ankle fractures in the elderly: an overlooked burden.

Ankle fractures in the elderly are a complex under-recognized burden which require a multidisciplinary approach to management. This article discusses the holistic approach required, including the up-to-date surgical management options and the areas for future development.

The efficacy of tranexamic acid in hip hemiarthroplasty surgery: an observational cohort study.

Tranexamic acid (TXA) has been shown to reduce perioperative blood loss in elective lower limb arthroplasty surgery. There are potentially even greater physiological benefits in minimising blood loss in hip fracture surgery, however limited evidence exists for TXA use in hemiarthroplasty surgery. This study investigates the effect of TXA use on postoperative transfusion rates and haemoglobin (Hb) levels specifically following hemiarthroplasty surgery for hip fractures. A retrospective cohort study was conducted for consecutive hip hemiarthroplasties for fractures between June 2013 and October 2014 comparing patients with or without prophylactic TXA before incision. During the study, 305 hemiarthroplasties were performed with 271 cases eligible. TXA was given in 84 (31%) cases, and both patient groups were matched for known confounding factors. Patients given TXA had a lower transfusion rate (6% vs. 19%. p=0.005) and less blood loss (Hb drop>20g/L) on day 1 post surgery (26% vs. 42%; p=0.014). One transfusion was prevented with every 8 patients given prophylactic TXA. There were no differences in the 30 and 90-day mortality rates with TXA use. Tranexamic acid is safe, cost-effective and reduces the need for blood transfusion and should be considered in all patients undergoing hip hemiarthroplasty for fractures.

Cement augmentation of the acetabulum for revision total hip arthroplasty for infection.

Antibiotic-loaded cement spacers in first-stage revision hip arthroplasty for infection are associated with a high dislocation and fracture rate. This technical note describes a novel surgical technique, utilizing screws and cement, improving acetabular coverage and reducing the risk of mechanical failure. Fifteen infected hip prostheses underwent removal, cement acetabular augmentation and insertion of a femoral cement spacer. Eleven hips had successful infection eradication and subsequently underwent a second stage revision procedure a mean duration of 15 weeks (9-48) after the first stage. No dislocations or fractures of the cement spacers were observed. This technique affords the potential to reduce the duration of time cement spacers remaining in situ, provides enhanced mechanical stability and improved antibiotic elution through cement-on-cement articulation.

Systematic review of high-volume multimodal wound infiltration in total knee arthroplasty.

Pain relief following total knee arthroplasty (TKA) is challenging because early mobilization and rehabilitation are essential for a successful outcome. Postoperative pain can limit recovery, leading to reduced mobility and prolonged hospitalization. There are potential benefits of infiltrating high volumes of local anesthetics around the soft tissues of replaced hip and knee joints. The risk of systemic toxicity is minimized with diluted local anesthetic solution, which also allows a high volume to be used. One of the principal advantages is that analgesia agents are administered intraoperatively by the surgeon, thereby minimizing the need for additional invasive procedures. The authors conducted a systematic review to evaluate whether high-volume multimodal wound infiltration reduces pain and opiate intake while enhancing early rehabilitation and discharge when used in patients undergoing TKA. Only randomized controlled studies were included. Although better pain relief in the immediate postoperative period with wound infiltration is gained after TKA, there is no definite evidence that this leads to a reduction in opiate consumption, the achievement of early milestones, or a reduction in hospital stay. The roles of individual agents in achieving pain relief and the use of percutaneous wound catheter for postoperative doses are also unclear. There are few reports of complications, including falls and delayed mobilization, when femoral nerve blocks are used. Wound infiltration analgesia should be used at the preference of the surgeon and anesthetist provided regular review of their practice is undertaken to identify any untoward side effects. Further randomized trials with sufficient sample size comparing each outcome, including pain scores, opiate consumption, and length of hospital stay, should be undertaken.

Patient-reported compliance with thromboprophylaxis using an oral factor Xa inhibitor (rivaroxaban) following total hip and total knee arthroplasty.

This prospective study examines patient non-compliance (NC) for an oral factor Xa inhibitor (Rivaroxaban) when used as venous thromboembolic (VTE) prophylaxis following lower limb arthroplasty. A total of 3145 patients underwent surgery from May 2010 to December 2011. At 6 weeks patients completed an anonymous self-administered questionnaire. Postoperatively 2947 (94%, 2947/3145) received Rivaroxaban. 2824 (96%, 2824/2947) completed all in-hospital doses. Seven percent (203/2824) of patients did not attend the 6-week follow-up. Two thousand one hundred sixty-three (83%, 2163/2621) completed all prescribed doses, 98 (4%, 98/2621) were NC and 360 (14%, 360/2621) had incomplete data. Gender, age, body mass index and preoperative hemoglobin all correlated with NC (p < 0.05). Type and side of surgery did not correlate with compliance (p > 0.05). Patient-reported NC for Rivaroxaban is 4% which compares favorably to other VTE prophylaxis modalities.

The results of total hip arthroplasty for fractured neck of femur in octogenarians.

The role of total hip arthroplasty (THA) for fracture in octogenarians remains unclear. Over a two-year period, 354 patients aged > 80 years were admitted with a displaced intracapsular hip fracture. Using defined clinical guidelines, 38 patients underwent THA with a median age of 84 years, mean follow-up of 20 months. Primary outcomes were dislocation, 30-day and one-year mortality, revision surgery and periprosthetic fracture. There were no dislocations or periprosthetic fractures and patient survival was 97% at 30 days and 87% at one year. There was one revision for deep infection. This study demonstrates that THA for selected octogenarians can be performed safely, allows the majority of patients to return to independent living and has a low complication rate.

Total hip arthroplasty for adult hip dysplasia.

Preoperative planning is essential to define anatomy, clarify the operative approach and exposure, and ensure that suitable implants are available.Concerns exist regarding the long-term effectiveness and safety of hip resurfacing arthroplasty for the young dysplastic hip.In light of current evidence, concerns exist regarding the use of metal-on-metal articulations for hip arthroplasty in the young dysplastic hip.The ideal bearing surface is not known, although the longest data available support the use of metal-on-polyethylene.

The management of rotator cuff tears in the elderly.

Rotator cuff tears occur commonly in the elderly causing significant pain and disability. In light of new treatment options developed over recent years, this article reviews the diagnosis and operative options available for this condition.

The reconstruction of periprosthetic pelvic discontinuity.

The surgical techniques and outcomes of acetabular reconstruction for periprosthetic pelvic discontinuity cases are reported. The mean time to surgery for 9 patients with acute pelvic discontinuity was 16.3 days, with 8 patients (88%) having posterior column plating and a porous metal acetabular cup. No cases required revision surgery, with a mean follow-up of 34 months (range, 24-67 months). Of the 62 chronic pelvic discontinuity cases, 20 had an ilioischial cage, with a revision rate of 29%. There were 42 cup-cage reconstructions with an 8-year survivorship of 86.3%, with a mean follow-up of 35 months (range, 24-93 months). Stable reconstruction of chronic pelvic discontinuity was achievable by distraction using a cup-cage acetabular reconstruction; however, satisfactory stability of acute pelvic discontinuity was achieved with compression of the posterior column using screw augmentation of the acetabular shell supplemented by posterior column plating.

Proximal femoral allograft in revision hip surgery with severe femoral bone loss: a systematic review and meta-analysis.

This study provides an objective appraisal of available evidence regarding the outcome of proximal femoral allograft for reconstruction of massive proximal femoral bone loss. The primary outcomes were rates of success, structural failure, and infection. A systematic literature review identified 16 studies with a minimum 2-year follow-up. Estimated pooled effect analysis performed with heterogeneity quantified using I(2) and τ(2). The total cohort included 498 patients with a mean follow-up of 8.1 years. The pooled success rate was 81%, pooled structural failure rate of 15%, and pooled infection rate of 8%. Significant heterogeneity was observed in structural failure rates (I(2) = 47.9, τ(2) = 0.29, P < .05). Proximal femoral allografts afford viable reconstruction for massive femoral bone loss when performed by experienced.