Increased fracture incidence in snow and ice conditions; a model for escalation.

Several studies have shown that the incidence of fractures during periods of snow and ice increases significantly and continues to persist despite preventative measures. The studies discussed in this article suggest that these predominantly consist of "walking wounded" with significant increase in demands in specific services such as the emergency department and the trauma and orthopaedic department. Traditionally, the only formal mechanism in place for most hospitals to react to extreme events is to declare a major incident. This is a binary, all or nothing response, and it is questionable whether an increase of snow and ice-related fractures would be justified in triggering such an extreme response. On the other end is the "do nothing" approach, which relies heavily on the professionalism, adaptability, and resilience of the staff to deal with the additional demand. The authors present a graded surge plan model for escalation in key resources, such as staff, space, and supplies in order to achieve the most efficient response ensuring good clinical outcome for patients.

Hip arthroplasty for acute hip fracture in patients with neurological disorders: A report Of 9,702 cases from the Swedish arthroplasty register.

INTRODUCTION: The purpose of this study was to investigate neurological disorder as a risk factor for dislocation following arthroplasty for acute hip fractures. We also analysed medical and surgical adverse events (AE), readmission, reoperation, revision, and mortality as secondary outcomes. METHODS: A longitudinal cohort study using prospectively collected and aggregated data from the Swedish Hip Arthroplasty Register (SHAR) and the Swedish national patient register. All patients presenting with an acute hip fracture and treated with an arthroplasty in the period from 2005 to 2014 from the SHAR were identified. Patients in receipt of bilateral arthroplasties were excluded. Patients with a relevant pre-existing and diagnosed neurological disorder, as defined by ICD-10 codes, were identified (n = 9,702). All other cases (n = 29,411) were available for logistic regression propensity score matching. Patients were 1:1 matched on age, sex, Charlson comorbidity index, total versus hemiarthroplasty, head size, surgical approach, and year of surgery. Dislocations, adverse events, readmission, reoperation, revision, and mortality were studied using Kaplan-Meier analysis and Cox regression. RESULTS: The risk of dislocations was higher for patients with neurological disorder (HR=1.19, CI 1.03- 1.39, p<0.05). Neurological disorder was associated with increased risk of encountering an adverse event (p<0.001 at 90-days); these patients were at higher risk of dying (HR=1.51, CI 1.47-1.56, p<0.001) however they were less likely to be readmitted (HR=0.73, CI 0.70- 0.76, p<0.001). No excess risks of reoperation (HR=1.02, CI 0.90-1.17; p = 0.73) or revision (HR=1.00, CI 0.86-1.17; p = 0.99) were identified in the study group. DISCUSSION: Compared to matched controls, individuals with a preoperatively identified neurological diagnosis had higher rates of mortality, dislocations, and adverse events, but this cohort was not at increased risk of reoperation or revision. This study highlights an area of focus for future research to improve the long-term outcomes in patients with neurological disease undergoing arthroplasty for an acute hip fracture.

Medium-Term Results of Arthroscopic Partial Meniscectomy from a Single High-Volume Center.

AIM: Clinical practice is moving away from treating meniscal tears in patients with osteoarthritis unless there are mechanical symptoms. This study assessed the risk of needing further surgery for osteoarthritis in the 5 years following partial meniscectomy in different age groups and different grades of knee osteoarthritis. METHODS: All partial meniscectomies were performed by the senior author during a 31-month period. Data were collected and analyzed retrospectively using electronic patients' records and imaging database. Patients who had previous arthroscopy, anterior cruciate ligament pathology, discoid meniscus or were less than 34 years old were excluded from the study. Range of follow-up was 3 to 5 years. Osteoarthritis was classified intra-operatively using the Outerbridge classification. Knees that needed further surgical treatment in the form of joint replacement or osteotomy were considered as failures. The population was split into three groups according to their age (35-54, 55-64 and 65+). Survival analysis was calculated using the life table method. RESULTS: 207 knees were included. In the 35-54 age group, patients with no/mild OA had a survival rate of 97.59% and the severe OA group had a survival rate of 73.5%. In the 55-64 age group, these figures were 100% and 73.6%, respectively. In the >65 age group, the survival rates were 100% and 65%, respectively. CONCLUSION: Our study shows that patients with no/mild OA should be considered for APM. Patient's with meniscal tears and severe OA should be counseled on the outcomes and risks of further surgery after an APM.

Outcome of revision arthroplasty for failed metal-on-metal total hip replacements; is there a relation with metal ions?

PURPOSE: We aimed to assess the early outcome following revision arthroplasty for failed metal-on-metal (MoM) total hip replacements (THR) due to adverse reaction to metal debris (ARMD). METHODS: We reviewed 106 consecutive revision arthroplasties. Case notes and radiological investigations were reviewed to assess the complications. Oxford Hip Score (OHS) and Euroqol (EQ-5D-3L) scores were used to assess the functional outcome and improvement of quality of life. RESULTS: At a mean follow-up of 20 months (12-48 months), the mean OHS was 28.7. Pain improved in 61% patients. A majority of patients were in level 2 for all the EQ-5D-3L dimensions. The overall complication rate was 16%. Survivorship free from further revision for any cause was 94.3% at 48 months. There was no correlation between pre-revision blood metal ions and the final outcome. CONCLUSIONS: Revision surgery for failed MoM hip replacement due to ARMD is associated with a relatively higher rate of complications and risk of chronic pain. There is poor correlation between serum metal ions and development of ARMD and outcome following revision surgery.

Bilateral sequential knee dislocation in a patient with connective tissue disorder: Report of an unusual case and lessons learnt.

Tibiofemoral knee dislocation is a rare but serious limb-threatening injury. Without prompt recognition and management, amputation or long-term functional impairment may result. The authors present a case of bilateral sequential knee dislocation, secondary to low-energy trauma, in a patient with Systemic Lupus Erythematosus and antiphospholipid syndrome. Adequate stability was achieved on both occasions by reconstruction of the postero-lateral corner and MCL. During the first reconstruction, ipsi-lateral autograft, as well as hamstring tendons from the contra-lateral side, were used to strengthen the graft. For the second reconstruction, allografts were used. This case highlights that, a patient with soft-tissue disorder presenting with low-energy knee dislocation may be at risk of further dislocations. Treating surgeons should anticipate these issues and consider the role of allograft in ligamentous repair.

Adverse reaction to metal bearing leading to femoral stem fractures: a literature review and report of two cases.

Metal-on-metal (MoM) bearing in total hip replacement (THR) has a high failure rate due to adverse reaction to metal debris (ARMD). There is a spectrum of soft tissue and bony changes in ARMD including muscle necrosis and osteolysis. In our institution, more than 1500 MoM THRs were implanted since 2003. Recently, we have revised significant numbers of these. We report our experience and management of a mode of failure of MoM THR that has been infrequently reported-the distal femoral stem fracture. We report on two patients who presented with worsening pain attributable to fracture of the femoral stem. Severe femoral osteolysis led to loss of proximal stem support and eventual fatigue fracture of the component. Both patients were revised employing a posterior approach. Bone trephine was used to extract a well-fixed distal stem fragment without any windows. Both patients had successful outcome after revision with excellent pain relief and no complications.

Epidemic of fractures during a period of snow and ice: has anything changed 33†years on?

OBJECTIVES: We reproduced a frequently cited study that was published in the British Medical Journal (BMJ) in 1981 assessing the extent of 'snow-and-ice' fractures during the winter period. SETTING: This study aims to provide an insight into how things have changed within the same emergency department (ED) by comparing the findings of the BMJ paper published 33 years ago with the present date. PARTICIPANTS: As per the original study, all patients presenting to the ED with a radiological evidence of fracture during three different 4-day periods were included. The three 4-day periods included 4 days of snow-and-ice conditions and two control 4-day periods when snow and ice was not present; the first was 4 days within the same year, with a similar amount of sunshine hours, and the second was 4 days 1 calendar year later. PRIMARY AND SECONDARY OUTCOME MEASURES: To identify the frequency, distribution and pattern of fractures sustained in snow-and-ice conditions compared to control conditions as well as comparisons with the index study 33 years ago. RESULTS: A total of 293 patients with fractures were identified. Overall, there was a 2.20 (CI 1.7 to 3.0, p <0.01) increase in risk of fracture during snow-and-ice periods compared to control conditions. There was an increase (p <0.01) of fractures of the arm, forearm and wrist (RR 3.2 (CI 1.4 to 7.6) and 2.9 (CI 1.5 to 5.4) respectively). CONCLUSIONS: While the relative risk was not of the magnitude 33 years ago, the overall number of patients presenting with a fracture during snow-and-ice conditions remains more than double compared to control conditions. This highlights the need for improved understanding of the impact of increased fracture burden on hospitals and more effective preventative measures.