Sharma's risk assessment score as a decision making tool to decide between total hip arthroplasty or hemiarthroplasty as a treatment option for elderly patients with fracture neck of femur. A prospective observational study.

Purpose: The decision to do a total hip arthroplasty (THA) or a hemiarthroplasty (HA) in an elderly with a fracture neck of femur (FNOF) is commonly based upon the surgeon's preference, pre-anesthetic fitness, hospital setup, and intensive care backup. The author devised a Sharma's risk assessment score (SRAS), based upon all the common factors that affect the surgical outcomes following FNOF in the elderly, to help orthopedic surgeons decide between THA or HA as a treatment for FNOF. Material & methods: It was a prospective observational study conducted in a tertiary-level institute. SRAS is based upon 10 parameters with each parameter having a max score of 4 and a minimum score of 1. So the maximum score a patient can score is 40 and the minimum a patient can score is 10. It was hypothesized that a patient with FNOF with a preop SRAS score >20 if subjected to a (HA) and a patient with a preop SRAS score ≤ 20 if subjected to a (THA) would have better outcomes and low complication rates. Out of Eighty-eight patients with FNOF, 7 were lost to follow-up. The remaining 81 patients with FNOF were prospectively followed between May 2018 and May 2022 and segregated into two groups THA (n = 47) and HA(n = 34) based on the SRAS. Results: The average length of follow-up was 2.6 years (6 months-4 years). The average SRAS was an average 25.7(21-32) in the HA group and 16.2 (11-20) in the THA group. Complications were seen in 12.7 % of the THA group and 17.6 % of the HA group. We had a 2.1 % 90-day mortality in the THA group and a 2.9 % 90-day mortality in the HA group. One year mortality in THA was 2.1 % and it was increased to 5.8 % in the HA group. Conclusion: SRAS is a useful decision-making tool that would guide surgeons to decide between THA or HA as a treatment option for elderly FNOF and would help minimize post-operative complications and reduce mortality. Level 3 study: Prospective observational study.

Preserving medial iliofemoral ligament avoids excessive leg lengthening in total hip arthroplasty using anterolateral-supine approach.

Background: In this study, we compared postoperative leg length discrepancy (LLD) after total hip arthroplasty using the anterolateral-supine approach (ALSA THA) with or without medial iliofemoral ligament (mILFL) preservation and examined the effect of the remaining mILFL on postoperative LLD. Methods: This was a single-center, retrospective case control study. Unilateral primary THA with a preoperative LLD <15 mm, in which the contralateral side was intact, was included. After ALSA THA, we compared the absolute values of postoperative LLDs and examined the ratio of postoperative LLD >5 mm with and without mILFL preservation. Demographic data, clinical scores, and operative data were collected. Statistical significance was set at p < 0.05. Results: We included 341 hips (preservation group: 283 hips; resection group: 58 hips). The mean (range) absolute values of the postoperative LLDs were 2.3 (0-15.9) mm and 3.4 (0-14.8) mm, respectively. There was no significant difference between the two groups (p = 0.36). The proportion of postoperative LLD >5 mm differed significantly between the groups (4.4 % and 20.0 %, respectively; p < 0.01). Multiple logistic regression analysis showed that resection of the mILFL was the only significant factor that caused excessive leg lengthening (odds ratio, 5.28; 95 % confidence interval, 2.12-13.10, p < 0.01). Significant differences were reported in surgical time (81 (38-132) and 96 (54-157), respectively; p < 0.01) and intraoperative blood loss (297 (50-1170) and 388 (100-1150), respectively; p < 0.01). However, no significant differences in clinical scores, dislocation (including instability), or reoperation rates were observed between the two groups. Conclusion: In patients with a preoperative LLD <15 mm, preserving the mILFL in ALSA THA avoids excessive leg lengthening and may lead to shorter LLD without any difficulties.

A pictographic guide for decision making in surgery for pelvic bone sarcoma.

Pelvic bone sarcoma surgery is challenging due to complex anatomy, proximity to major neurovascular structures, and, more importantly, the potential for complications. Decision-making is vital in offering patients the best oncological and functional outcomes after surgery. Multidisciplinary teams involved from the stage of diagnosis and treatment planning, followed by surgery by experienced teams have proven to be beneficial. Tumour-free margin clearance is essential, and surgical planning must be tailored to achieve the same. The choice of reconstruction needs to be decided based on the amount of bone resected and the available expertise and resources. Lesions isolated only to PI or PIII region may not need reconstruction. Though pedestal cups and Custom-made prosthesis are useful in reconstruction after periacetabular tumour resections, hip transposition surgery is also widely practiced by surgeons with favourable outcomes particularly after neo-adjuvant radiotherapy/proton beam therapy. Navigation has shown promise in achieving tumour-negative margins and disease-free progression particularly in chondrosarcoma. A flap-based approach can be considered for hindquarter amputations; however, patients need to be counseled regarding the complications following this surgery. This article, with proposed flowcharts, is aimed at providing practicing surgeons with a guide toward decision-making while planning pelvic bone sarcoma surgery.

Greater readmission rates after total hip arthroplasty with discharge to a facility vs. home: A propensity score matched analysis.

Purpose: Provided that total hip arthroplasties (THA) are some of the most common surgical procedures performed, there is a necessity to understand all factors that contribute to risks of adverse outcomes postoperatively and to find solutions to avoid these events with preventive measures. This retrospective cohort study sought to assess differences in (1) postoperative complication rates, (2) readmission rates and reasons, and (3) demographic variables that contribute to readmissions based on discharge destination within the first 30 days after a THA. Methods: Patients undergoing THA (27130) between 2015 and 2020 were extracted from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database based on procedural codes. Propensity score matching was then employed to reduce selection bias, and Chi-square tests and one-way analysis of variance (ANOVA) were performed. Multivariable analysis was then used to look for other factors associated with readmission risk. Results: 219,960 patients were identified with 189,841 discharged to home, 19,355 to a skilled nursing facility (SNF), and 10,764 to a rehabilitation facility. The rehabilitation and SNF cohorts both had greater rates of readmission (4.56 % home vs. 6.88 % SNF vs. 6.90 % rehabilitation, P<0.001) and any adverse event (AAE, 9.02 % vs. 18 % vs. 21.3 %, P<0.001) after matching. Older age, longer operative time, American Society of Anesthesiologists (ASA) classification four, chronic obstructive pulmonary disease (COPD), bleeding disorders, steroid use, and smoking were associated with an increased risk of readmission after THA. Conclusion: Overall, THAs were shown to have low postoperative complications and readmissions in all patient populations despite differences in discharge destination which continues to demonstrate the safety and validity of this often elective procedure. However, the statistically significant risk of complications and readmissions in addition to the higher costs associated should be accounted for when considering patient discharges to a non-home facility.

Mitigating calcar fracture risk with automated impaction during total hip arthroplasty.

Background: Automated broaching has recently been introduced for total hip arthroplasty (THA), with the goal of improving surgical efficiency and reducing surgeon workload. While studies have suggested that this technique may improve femoral sizing and alignment, little has been published regarding its safety, particularly with regard to calcar fractures. The purpose of our study was to evaluate the risk of calcar fracture during automated broaching, and to determine if this risk can be mitigated. Methods: We queried our prospective institutional database and identified 1596 unilateral THAs performed by the senior author using automated impaction between 2019 and 2023. We identified the incidence of calcar fracture with automated impaction, and whether the fracture occurred during broaching or stem insertion. We additionally determined calcar fracture incidence within two consecutive subgroups of patients using different stem insertion techniques; subgroup (1): automated broaching with automated stem insertion for all patients; versus subgroup (2): automated broaching with automated stem insertion ONLY if a cushion of cancellous bone separated the broach from the calcar, otherwise the stem was placed manually. Continuous and categorical variables were analyzed with Student's t-test and Fisher's exact test, respectively. Results: Seventeen calcar fractures occurred intraoperatively (1.1 %). Only two fractures occurred during automated broaching (0.1 %), while fifteen occurred during final stem impaction (0.9 %) (p = 0.007). Four calcar fractures (1.4 %) occurred in subgroup 1, compared to two in subgroup 2 (0.6 %) (p = 0.28). Conclusions: Our study found a calcar fracture incidence of 1.1 % using automated impaction, consistent with historically reported rates of 0.4-3.7 %. We found that calcar fractures are more likely to occur during stem insertion than during femoral broaching. We recommend that if any part of the final broach is in direct contact with the calcar, the final stem should be impacted manually to minimize fracture risk.

Short-term outcomes with routine use of size ≥40 femoral heads in THA: A retrospective cohort study.

Background: Using larger femoral heads during total hip arthroplasty (THA) may result in a more stable hip. Greater volumetric wear and frictional torque, however, may result in increased postoperative complications. The purpose of this study was to compare outcomes of patients with femoral head size ≥40 mm compared to those with femoral head size <40 mm. Materials and methods: A retrospective chart review of 504 THAs performed by a single surgeon at a single institution from 2009 to 2016 was conducted. Following exclusions, 131 THAs were identified with femoral heads ≥40 mm and 348 THAs were identified with femoral heads <40 mm. In addition to demographic data, all postoperative complications were recorded. Plain radiographs were used to rule out/in periprosthetic osteolysis and/or acetabular loosening. Chi-square tests and Student's t-tests were used to compare categorical and continuous variables, respectively. Results: Mean follow-up period for the entire cohort was 5.5 years. Complications with ≥40 mm femoral heads included 1 superficial infection and 1 deep periprosthetic joint infection (PJI). There were no cases of dislocation, osteolysis, acetabular loosening, or trunnionosis. In contrast, complications with <40 mm femoral heads included 9 dislocations and 7 PJIs. Conclusion: The routine use of large femoral heads (≥40-mm) during THA appears to be a safe option for patients at short-term clinical follow-up. Notably, 0 patients had a clinical course complicated by dislocation, osteolysis, acetabular loosening, or trunnionosis. Level of evidence: Level III Retrospective Cohort Study.

Outcomes of salvage total hip arthroplasty after failed cannulated screw fixation of fractured neck of femur.

Introduction: In a UK setting, cannulated hip screws (CHS) are frequently used to fix femoral neck fractures. Although often a relatively quick procedure and one that is delegated to more junior surgeons, failure rates of up to 23 % have been reported. The salvage procedure is total hip arthroplasty (THA). In this paper we report the outcomes of a series of THA for failed cannulated screw fixation. Methods: Retrospective analysis of one of the largest reported single cohort of 600 CHS procedures spanning 14 years from 2007 to 2020 from a single centre was performed. This identified 55 patients who went on to have total hip arthroplasty, 36 women, 19 men, mean (SD) age: 71.5 (13.6) years. Patient characteristics, reason for fixation failure and complications were recorded. Oxford hip scores were available for 47 patients. Comparison was made with a series of patients who underwent primary THA for fracture. Results: Failure rate of CHS was 9.2 % in our cohort. Mean (SD) time from fixation to arthroplasty was 15.5 (12.4) months. Two patients (3.6 %) patients had a postop complication, one requiring further surgery. Mean (SD) preoperative Oxford hip score was 11.4 (8.0). This improved to 38.8 (10.4) at 1 year and 32.1 (14.9) at 5 years postoperatively. This compares to a mean (SD) of 39.7 (8.6) at 1 year and 39.4 (8.1) at 5 years in a group of 185 patients undergoing primary THA for hip fracture. Displaced fractures that went on to failure had better postop scores than nondisplaced fractures. Discussion: The failure rate of CHS is relatively low and the salvage procedure of THA has a minimal complication rate and outcomes as good as primary THA for hip fracture.

What is the multifactorial efficacy of day-zero ambulation post-total hip replacement surgery: A systematic review.

Objective: To examine the multi-factorial efficacy of day-zero ambulation following primary total hip arthroplasty. Data sources: MEDLINE, CINAHL, AMED, EMBASE and APA PsychInfo in accordance with PRISMA guidelines. Review methods: Studies were classified for study design and ranked in a hierarchy of evidence. Studies ranked excellent or good who followed a treatment pathway inclusive of day-zero ambulation were appraised using the appropriate content checklist (PRISMA, CONSORT, STROBE), CASP checklist and where possible for risk of bias using the appropriate tool (RoB 2.0, ROBINS-1). Results were produced using a narrative synthesis. Results: A total of 8 studies met inclusion criteria. Studies reported a consensus of a reduced length of hospital stay in pathways where day-zero ambulation was included, but with varying effect sizes. Findings suggested that day-zero ambulation may speed up return to function following THR. There was not enough evidence to provide synthesised results on financial efficiency, post-operative pain, or safety of day-zero ambulation via post-operative complications. Conclusions: This systematic review reveals limitations within the literature base on day zero-ambulation. There are problems of concomitant interventions, methodological heterogeneity, and an abundance of research low in the evidence hierarchy. Day zero-ambulation shows promise in reducing length of hospital stay and there is suggestion that it accelerates functional recovery. However, to establish this with rigor, there is further need for high quality, prospective studies such as RCTs to examine the multi-factorial effect of day-zero ambulation, challenge existing theories and contribute to confident synthesised findings more useful to clinical decision makers.

Impact of tranexamic acid use in total hip replacement patients: A systematic review and meta-analysis.

Purpose: Tranexamic acid (TXA) dose in the context of primary complete hip replacements (THA) is still a hot debate about the best way to administer TXA. The need to select the most efficient and secure TXA dosing regimen, taking into account elements like perioperative bleeding, postoperative complications, and patient outcomes, has been emphasized by numerous studies. Improving clinical procedures and the general efficacy and safety of employing TXA in THA surgeries requires addressing this ongoing debate. Methods: For this systematic review, We looked at the safety and efficacy of administering TXA intravenously (iTXA) and topically (tTXA) during THA. A thorough search turned up ten randomized controlled trials with 1295 individuals. Parameters evaluated included blood loss, Hb level on the day following surgery, transfusion rates, and drainage volume. Results: Strategies had comparable impacts on deep vein thrombosis occurrences and wound complications. iTXA produced considerably less intraoperative blood loss (WMD = -12.687), concealed blood loss (WMD = 14.276), and the greatest hemoglobin drop (WMD = -0.400) when compared to tTXA. Conclusion: Both administration techniques were secure and efficient in primary THA, although iTXA showed superior results in lowering blood loss and Hb decline.

Comparison of cost and complications of primary total hip arthroplasty versus oncologic proximal femur replacement.

Aims and objective: Proximal femur replacement (PFR) is most commonly performed after a large resection of the proximal femur to remove tumor and is known to have high complication rates and worse function than a primary total hip replacement (THA). Many surgeons feel that current billing practices fail to adequately differentiate this procedure from a THA. This study aims to examine patients undergoing a primary THA or oncologic PFR and compare the relative economic impact and complication rates between cohorts. Materials & methods: Patient data was queried using a national database, identifying non-pediatric patients who underwent a primary THA or oncologic PFR. Exclusionary criteria were implemented, resulting in two cohorts, each with 380 patients matched in a 1:1 manner controlling for age, gender, and Charlson Comorbidity Index. Utilizing 2022 billing data, oncologic PFRs generated an average of 41.03 RVUs and primary THAs generated 19.60 RVUs. Total hospital cost was used to generate a cost:RVU ratio for each cohort. Key systemic and joint complication rates were additionally compared between cohorts. Results: The oncologic PFR cohort had significantly higher 90-day rates of anemia, deep vein thrombosis, and prosthetic dislocation compared to the primary THA cohort. The 90-day median hospital cost for oncologic PFR was $28,562.21 with a cost:RVU ratio of $696:1. The corresponding median hospital cost for primary THA was $9667.72, with a cost:RVU ratio of $493:1. Conclusion: Hospitals incur more cost per RVU for an oncologic PFR than a primary THA. Relative to primary THA, reimbursement for oncologic PFR is under-evaluated.

Comparison of outcomes after total hip arthroplasty in hip fracture versus elective cases in patients over 60 years of age.

Background: Total hip arthroplasty (THA) allows for the replacement of impaired parts of the hip joint with artificial ones. This study aimed to compare the differences in preoperative patient profiles, postoperative complications, and clinical outcomes of two patient groups: those who underwent THA for fractures and those who underwent THA electively for diseases such as osteoarthritis (OA) and avascular necrosis (AVN). Methods: We retrospectively analyzed the data of patients who underwent THA between March 2012 and December 2021. Of 232 patients, 173 patients who met the exclusion and inclusion criteria were included. Patients were divided into two groups (Group 1: 113 patients diagnosed with OA or AVN; Group 2: 60 patients diagnosed with hip fracture). Pre- and postoperative Visual Analogue Scale (VAS), Koval scores, and postoperative modified Harris Hip Score (mHHS) were used to assess clinical outcomes. Demographic data and postoperative complications of the two groups were compared. After surgery, a rehabilitation protocol was initiated. Results: Patients in Group 2 (fracture) had more preoperative comorbidities than those in Group 1 (elective). Follow-up months are 26.22 ± 19.78 (Group 1), and 27.42 ± 17.02 (Group 2) respectively (P > 0.05). There were no statistical differences in the prevalence of postoperative complications between two groups (P > 0.05). Compared with Group 1(elective), Group 2(fracture) showed lower VAS (P < 0.01) at last follow-up, and no difference in Koval score (P = 0.77) and mHHS (P = 0.96) at last follow-up. Conclusion: Considering the characteristics of the two groups and their perioperative multidisciplinary care, THA for hip fractures can provide good clinical results compared to those with elective THA.

Geographical incidence of testosterone supplementation in total hip and knee arthroplasty.

Introduction: Prescription testosterone usage in the United States declined after 2013 following reports of its association with myocardial infarction and stroke. However, more recently there has been a documented increase in testosterone prescriptions. Recently, testosterone levels have also been hypothesized to increase infection risk in patients undergoing elective shoulder arthroplasty. Furthermore, testosterone may increase the risk of venous thromboembolism. These complications are perioperative concerns for total hip and knee arthroplasties (THA/TKA). Therefore, the purpose of our study is to identify trends in the incidence of testosterone prescriptions in patients who underwent THA/TKA with respect to geographical population data. Methods: We retrospectively reviewed 40,711 primary THAs and 50,893 primary TKAs performed in males between 1/1/2016 and 12/31/2021 using a commercial claims database. Records were reviewed for demographics, geographical location, and supplemental testosterone prescriptions within 1 year prior to surgery. Patient Metropolitan Statistical Area (MSA) was assessed with respect to United States Census Population Data. Results: We identified 91,604 males who underwent primary THA (n = 40,711) or TKA (n = 50,893). For THA/TKA, patients who were younger had a higher likelihood of having a supplemental testosterone prescription (OR = 0.99, 95 % CI [0.99-1.00], p < 0.001). TKA patients (2,507, 4.9 %) had a higher rate of testosterone prescriptions than THA patients overall (1,413, 3.4 %), (OR = 1.44 95 % CI [1.35, 1.54], p < 0.001) as well as within each year.For THA and TKA patients, patients in the Midwest (OR = 1.61, p < 0.001), South (OR = 3.04, p < 0.001), and West (OR = 2.28, p < 0.001) regions all had higher testosterone prescription rates than the Northeast. Patients living in a city (MSA population ≥200,000) were more likely to be prescribed testosterone (OR = 1.20, p = 0.002). Conclusion: Surgeons conducting TKA/THA should be aware that younger patients, those in higher population areas, and those in the Midwest, South, and West regions are more likely to be prescribed testosterone than those in the Northeast.

[Improving the Accuracy of Patient Self-Care After Joint Replacement Surgery].

BACKGROUND & PROBLEMS: Joint replacement wound stitches are typically not removed until two weeks after the operation. Therefore, patients with joint replacement must be able to execute proper wound care after discharge from the hospital to reduce the risk of wound infection. Prior data from Chang Gung Memorial Hospital's orthopedics ward indicate only 69% of joint-replacement patients are able to perform wound care properly at home. Potential causes for this noted by patients include age-related forgetfulness, being unable to discern redness or swelling in the wound, and language comprehension difficulties (i.e., Taiwanese vs. Mandarin). Poor rates of wound care may also be attributable to incomplete wound care education by nursing staff and wound care education being provided without adequate practice on the day of patient discharge. PURPOSE: This project was implemented to improve the accuracy of wound self-care performed by patients after joint replacement surgery and to enhance their related knowledge and wound-care technical correctness. RESOLUTION: A wound care education checklist, wound care cue cards, wound care video clips, wound condition red flag cue cards, and customized wound care pack were proposed and implemented. RESULTS: The rate of accuracy of wound self-care performance increased from 69% pretest to 98% posttest, showing the intervention to have effectively improved post-discharge wound care quality. CONCLUSIONS: To effectively improve the post-discharge accuracy of wound self-care in patients with joint replacement, the consistency of post-surgery wound care education given by nursing staff to patients should be improved, patients should be reminded of wound assessment and care steps, and patients should be aware that wound abnormalities require an immediate return to the hospital for follow-up treatment.

Vitamin D and hip protectors in osteosarcopenia: a combined hip fracture preventing approach.

Osteosarcopenia is an emerging clinical condition highly prevalent in the older people. Affected subjects due to their intrinsic skeletal fragility and propensity to falls are at elevated risk of hip fractures which can increase morbidity and mortality. Strategies for attenuating the impact of predisposing factors on hip fractures are not yet well defined and should derive from multidisciplinary care and collaborations. Our aim was to narratively review available data on the preventive role of vitamin D and hip protectors on hip fractures in older patients with sarcopenia. Older subjects are at high risk of vitamin D deficiency and of falls due to several concomitant factors besides osteosarcopenia. Vitamin D protective actions against hip fractures may be mediated by both skeletal (increased mineralization) and extra-skeletal (reduced risk of falls) actions. Hip protectors may act downstream attenuating the effects of falls although their use is still not yet enough widespread due to the suboptimal compliance obtained by traditional hard devices. Concomitant use of vitamin D and hip protectors may represent an effective strategy in the prevention of hip fractures which need to be tested in ad hoc designed clinical trials.

Diagnostic accuracy of point-of-care ultrasound (PoCUS) for the diagnosis of hip effusion in the pediatric emergency department.

PURPOSE: A new limp or refusal to weight-bear are common symptoms in children presenting to the pediatric emergency department (ED). This poses a diagnostic challenge, particularly among toddlers and nonverbal patients. Point-of-care ultrasound (PoCUS) used by pediatric emergency medicine physicians may detect hip effusion, which dramatically aids diagnostic workup and management. There is limited literature regarding the accuracy of hip PoCUS conducted by pediatric emergency medicine physicians. This study aims to assess the diagnostic performance of pediatric emergency medicine physician-performed PoCUS in identifying hip effusion. METHODS: This prospective study was conducted in a single-center pediatric ED. Children presenting with limb pain or new limp were evaluated by pediatric emergency medicine physicians who also performed hip PoCUS and categorized findings as either "effusion" or "no effusion" based on standard sonographic definitions. Patients also underwent radiology department ultrasound reviewed by a pediatric radiologist. Diagnostic test characteristics with corresponding 95% confidence intervals (CI) were calculated using radiology department ultrasound findings as the reference standard. RESULTS: A total of 95 patients were enrolled by 8 pediatric emergency medicine physicians. Excellent agreement was observed between PoCUS performed by pediatric emergency medicine physicians and radiology department ultrasound for the presence or absence of hip effusion (kappa = 0.81 [95% CI 0.70-0.93]). Hip effusion was identified by PoCUS in 44 out of 49 effusion-positive patients, with a sensitivity of 89.8% (95% CI 77.7-96.6%), specificity of 91.3% (95% CI 79.2%-97.5%), positive likelihood ratio of 10.33 (95% CI 4.03-26.47), and negative likelihood ratio of 0.11 (95% CI 0.05-0.26). CONCLUSION: PoCUS performed by pediatric emergency medicine physicians has reasonably high sensitivity and specificity for diagnosing hip effusion among pediatric patients presenting to the pediatric ED with a limp or leg pain. This practice may potentially expedite both diagnosis and treatment within this patient population.

RéSUMé: OBJECTIF: Un nouveau boiteux ou un refus de porter le poids sont des symptômes courants chez les enfants qui se présentent à l'urgence pédiatrique (DE). Cela pose un défi diagnostique, en particulier chez les enfants en bas âge et les patients non verbaux. Les échographies de point de soins (PUCU) utilisées par les médecins des urgences pédiatriques peuvent détecter un épanchement de la hanche, ce qui facilite considérablement le diagnostic et la gestion. Il existe une littérature limitée concernant la précision des PUC de la hanche effectuée par les médecins urgentistes pédiatriques. Cette étude vise à évaluer la performance diagnostique des PUCU réalisées par un médecin en médecine d'urgence pédiatrique pour identifier l'effusion de la hanche. MéTHODES: Cette étude prospective a été menée dans un seul centre de DE pédiatrique. Les enfants présentant une douleur aux membres ou une nouvelle boiterie ont été évalués par des médecins pédiatriques d'urgence qui ont également effectué un PUCU de la hanche et ont classé les résultats comme "épanchement" ou "aucun épanchement" selon les définitions échographiques standard. Les patients ont également subi une échographie du service de radiologie examinée par un radiologue pédiatrique. Les caractéristiques des tests diagnostiques avec leurs intervalles de confiance (IC) correspondants à 95 % ont été calculées en utilisant les résultats d'échographie du service de radiologie comme norme de référence. RéSULTATS: Un total de 95 patients a été inscrits par huit médecins urgentistes pédiatriques. Une excellente concordance a été observée entre les ultrasons réalisés par les médecins pédiatriques d'urgence et ceux du service de radiologie pour la présence ou l'absence d'effusion de la hanche (kappa = 0.81 [IC à 95% 0.70­0.93]). Le épanchement de la hanche a été identifié par PUCU chez 44 des 49 patients ayant un épanchement positif, avec une sensibilité de 89,8 % (IC à 95%, 77.7 ­96.6 %), une spécificité de 91,3 % (IC à 95%, 79.2­97.5%), un rapport de vraisemblance positif de 10,33 (IC à 95 %, 4.03­26.47) et un rapport de vraisemblance négatif de 0,11 (IC à 95% 0.05-0.26) CONCLUSIONS: Le PUCU réalisé par des médecins pédiatriques d'urgence a une sensibilité et une spécificité raisonnablement élevées pour diagnostiquer l'épanchement de la hanche chez les patients pédiatriques présentant une lésion ou une douleur aux jambes. Cette pratique pourrait accélérer le diagnostic et le traitement dans cette population de patients.

Unexpected positive cultures in conversion hip and knee arthroplasty.

PURPOSE: Total hip and knee arthroplasty in patients with previous history of periarticular surgery, such as osteosynthesis, can be surprisingly complex. This type of procedure is known as conversion arthroplasty (cTHA or cTKA) and has a higher risk of complications. The rates of unexpected positive cultures (UPC) and the risk of periprosthetic joint infection (PJI) compared to primary arthroplasty is unclear. The main purpose of this study was to evaluate rates of Unexpected Positive Cultures (UPC) in a series of conversion arthroplasty patients. The main questions to answer are: 1. Are the patients with conversion arthroplasties more susceptible to UPC than other causes of revision arthroplasties? 2. Are the conversion patients with UPC more susceptible to developing PJI? METHODS: This was a retrospective review of patients submitted to cTHA and cTKA from January 2012 to September 2018. Patients with history of previous infection or with missing intraoperative cultures were excluded. The UPC was defined as a single positive culture obtained during a procedure previously considered aseptic and PJI was defined according to the 2018 ICM criteria. After excluding 141 cases, 205 patients were analyzed, 160 hips and 45 knees. RESULTS: Nine (4.4%) UPC were identified, five (3.1%) in the hip group and four (8,9%) in the knee group. Staphylococcal species were the most common isolated bacteria (n = 7, 77.7%). During the study period, four (1,9%) patients were diagnosed with PJI. Only one case had an UPC and a different germ was identified during revision arthroplasty workup. CONCLUSIONS: While UPC are more prevalent in conversion knee arthroplasties compared to conversion hip arthroplasties, the rates are similar to those observed in revision arthroplasty for other indications. Importantly, the presence of a UPC in conversion arthroplasty does not appear to elevate the risk of subsequent periprosthetic joint infection, provided a thorough PJI workup has been conducted preoperatively. Therefore, in such cases, UPCs may be safely disregarded.

How accurately do finite element models predict the fall impact response of ex vivo specimens augmented by prophylactic intramedullary nailing?

Hip fracture prevention approaches like prophylactic augmentation devices have been proposed to strengthen the femur and prevent hip fracture in a fall scenario. The aim of this study was to validate the finite element model (FEM) of specimens augmented by prophylactic intramedullary nailing in a simulated sideways fall impact against ex vivo experimental data. A dynamic inertia-driven sideways fall simulator was used to test six cadaveric specimens (3 females, 3 males, age 63-83 years) prophylactically implanted with an intramedullary nailing system used to augment the femur. Impact force measurements, pelvic deformation, effective pelvic stiffness, and fracture outcomes were compared between the ex vivo experiments and the FEMs. The FEMs over-predicted the effective pelvic stiffness for most specimens and showed variability in terms of under- and over-predicting peak impact force and pelvis compression depending on the specimen. A significant correlation was found for time to peak impact force when comparing ex vivo and FEM data. No femoral fractures were found in the ex vivo experiments, but two specimens sustained pelvic fractures. These two pelvis fractures were correctly identified by the FEMs, but the FEMs made three additional false-positive fracture identifications. These validation results highlight current limitations of these sideways fall impact models specific to the inclusion of an orthopaedic implant. These FEMs present a conservative strategy for fracture prediction in future applications. Further evaluation of the modelling approaches used for the bone-implant interface is recommended for modelling augmented specimens, alongside the importance of maintaining well-controlled experimental conditions.

Efficacy of Outside-In Hip Arthroscopy without Traction in the Treatment of Hip Synovial Osteochondromatosis.

Arthroscopic treatments of hip synovial osteochondromatosis are mostly performed under traction, resulting in neurovascular injury or iatrogenic damage to the labrum or cartilage. This study aimed to assess the effectiveness of outside-in hip arthroscopy without traction in treating hip synovial osteochondromatosis. This retrospective study was conducted on a series of patients with hip synovial osteochondromatosis treated using outside-in hip arthroscopy without traction in our hospital between 2018 and 2020. Plain radiography and magnetic resonance imaging (MRI) scans were obtained. The Harris hip score (HHS), hip range of motion (ROM), and visual analog scale (VAS) scores were analyzed. The preoperative scores and last follow-up scores were compared with a paired-sample t test. The complications and recurrence postsurgery were recorded. This study included five patients (three male and two female) with an average age of 41 years (range 28-54 years). The mean follow-up time was 25.2 months (range 18-36 months). All patients experienced groin pain relief and improved ROM. The mean VAS score was significantly lower postoperatively (0.4 ± 0.5) than preoperatively (3.2 ± 0.8) (p < 0.001). The mean HHS improved from 58.6 ± 12.7 (range 43-73) to 89.8 ± 5.26 (range 81-95) (p < 0.001). No major complications, including infection, perineal numbness and swelling, neurotrosis, thromboembolism, or severe persistent pain, were reported. Synovial osteochondromatosis recurred in one patient after 2 years of follow-up without any obvious symptoms such as hip pain or joint locking. Therefore, no further treatment was necessary. This study showed that outside-in hip arthroscopy without traction might be a viable option for treating hip synovial osteochondromatosis, effectively and safely relieving symptoms with minimal complications, especially in patients without lesions in the central compartment.

Is the continuity of the therapist-patient relationship relevant for the discharge outcome in orthopaedic physical rehabilitation?

Continuity of care has been linked to patient satisfaction and self-reported outcomes. Following hip fractures in the elderly, rehabilitation aims at restoring patients' mobility and independence at the pre-fracture level and at the earliest possible time. Despite the potential role of physiotherapists' continuity on functional outcomes, this correlation has not yet been studied in an acute orthopaedic setting. Guaranteeing the presence of the same physical therapist on individual patients is challenging from an organizational point of view. An observational retrospective study was conducted on 129 aged patients (84 ± 8 years) who underwent surgery for proximal hip fracture. Indicators of outcomes were ILOA score at discharge, length of stay and achievement of rehabilitation goals as defined by the Individual Rehabilitation Project. The number of physical therapists taking care of patients was monitored during the patient's hospital stay. No correlation was found between the number of physical therapists and functional goals at discharge. The frequent change of physical therapists providing rehabilitation to elderly patients who underwent surgery for hip fragile fracture is not related to functional outcomes.

Unveiling the dynamics of intraoperative contamination in total hip arthroplasty: the discrepancy between particulate and microbial contamination in surgical site infection risk.

BACKGROUND: Surgical site infection (SSI) is a major problem following total hip arthroplasty (THA). This study investigated the impact of a standard intraoperative routine where the surgical team wears full-body exhaust suits (space suits) within a laminar airflow (LAF)-ventilated operating room (OR) on environmental contamination. Our primary objective was to identify potential modifiable intraoperative factors that could be better controlled to minimize SSI risk. METHODS: We implemented an approach involving simultaneous and continuous air sampling throughout actual primary cementless THA procedures. This method concurrently monitored both airborne particle and microbial contamination levels from the time the patient entered the OR for surgery until extubation. RESULTS: Airborne particulate and microbial contamination significantly increased during the first and second patient repositionings (postural changes) when the surgical team was not wearing space suits. However, their concentration exhibited inconsistent changes during the core surgical procedures, between incision and suturing, when the surgeons wore space suits. The microbial biosensor detected zero median microbes from draping to suturing. In contrast, the particle counter indicated a significant level of airborne particles during head resection and cup press-fitting, suggesting these procedures might generate more non-viable particles. CONCLUSIONS: This study identified a significant portion of airborne particles during the core surgical procedures as non-viable, suggesting that monitoring solely for particle counts might not suffice to estimate SSI risk. Our findings strongly support the use of space suits for surgeons to minimize intraoperative microbial contamination within LAF-ventilated ORs. Therefore, minimizing unnecessary traffic and movement of unsterile personnel is crucial. Additionally, since our data suggest increased contamination during patient repositioning, effectively controlling contamination during the first postural change plays a key role in maintaining low microbial contamination levels throughout the surgery. The use of sterile gowns during this initial maneuver might further reduce SSIs. Further research is warranted to investigate the impact of sterile attire on SSIs.