Comprehensive Guidance for the Prevention of Periprosthetic Joint Infection After Total Joint Arthroplasty and Pitfalls in the Prevention.

Total joint arthroplasty (TJA) is a surgical procedure, in which parts of damaged joints are removed and replaced with a prosthesis. The main indication of TJA is osteoarthritis, and the volume of TJA is rising annually along with the increase of aged population. Hip and knee are the most common joints, in which TJAs are performed. The TJA prosthesis is composed of metal, plastic, or ceramic device. Even though TJA is the most successful treatment for end-stage osteoarthritis, it is associated with various complications, and periprosthetic joint infection (PJI) is the most serious complication after TJA. With the increasing volume of TJAs, there is a simultaneous rise in the incidence of PJI. Contamination of the surgical wound and the adherence of bacteria to the surface of prosthetic component represent the initial step in the pathogenesis of PJI. The main sources of the contamination are 1) patient's own flora, 2) droplets in the operation room air, and 3) surgical gloves and instruments. Even though modern techniques have markedly reduced the degree of contamination, TJAs cannot be done in completely germ-free conditions and some degree of contamination is inevitable in all surgical procedures. However, not all contamination leads to PJI. It develops when the burden of contamination exceeds the immune threshold or the colony forming units (CFUs) and various factors contribute to a decrease in the CFU level. Surgeons should be aware of the germ burden/CFU concept and should monitor sources of contamination to maintain the germ burden below the CFU to prevent PJI.

A Meta-Analysis of Polymerase Chain Reaction for Prosthetic Joint Infection Diagnosis.

BACKGROUND: One of the most dangerous side effects of joint replacement for the hip, knee, shoulder, and elbow is prosthesis joint infection (PJI). Polymerase chain reaction (PCR) has been considered a promising method for PJI diagnosis due to its short diagnostic time and high sensitivity. Although several PCR methods such as multiplex PCR and broad-range PCR are useful diagnostic methods for detecting microorganisms causing PJI, values of different PCR methods for the diagnosis of PJI remain unclear. Thus, the objective of this study was to perform a meta-analysis of different PCR methods in the diagnosis of PJI to determine their diagnostic characteristics including sensitivity and specificity. METHODS: The following data were extracted: PCR method, number of patients, sample site and type, diagnosis standard, true positive, false positive, false negative, and true negative. Pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio were calculated. Meta-regression analysis was conducted to assess heterogeneity. Subgroup analysis was also performed to assess effects of several variables on meta-analysis results. RESULTS: The current study showed that pooled sensitivity and pooled specificity were 0.70 (95% CI: 0.67 - 0.73) and 0.94 (95% CI: 0.92 - 0.95), respectively. Results of subgroup analysis indicated that sequencing method showed the lowest sensitivity (0.63, 95% CI: 0.59 - 0.67). However, after excluding studies using tissue samples directly, sequencing method showed higher sensitivity (0.83, 95% CI: 0.73 - 0.90) than other PCR methods (0.74, 95% CI: 0.69 - 0.78). CONCLUSIONS: The main significance of this study was that we attempted to classify accuracies of several PCR methods and found that sequencing with a reliable sampling method could be used as an early screening strategy for PJI. Further comparisons for PCR technologies are needed to evaluate their cost effectiveness and diagnostic procedures, not just diagnostic values, to discover the optimal one for PJI diagnosis.

Pre-sliding of femoral neck system improves fixation stability in pauwels type III femoral neck fracture: a finite element analysis.

BACKGROUND: Femoral neck fractures are a common injury in older adults and their management presents a significant challenge for orthopedic surgeons. The Femoral Neck System (FNS) was recently introduced for the fixation of femur neck fractures. Although neck shortening was reduced with the FNS, the complication rates were not reduced. Thus, improvements to enhance fixation stability should be made for the FNS. We hypothesized that (1) the pre-sliding technique and (2) the use of longer anti-rotation screw would increase fracture stability. This study aimed to determine the change in fracture stability using the pre-sliding technique and long anti-rotation screw in the FNS for fixation of Pauwels type III femoral neck fractures. METHODS: Finite element models of Pauwels type III femoral neck fracture fixed with pre-sliding FNS and 5-mm longer anti-rotation screw were established. The models were subjected to normal walking load. The material properties of the elements belonging to the bone were mapped by assigning the formulation with the computed tomography Hounsfield unit. RESULTS: Pauwels type III femoral neck fractures fixed with pre-slided FNS showed better fracture stability, decreasing fracture gap and sliding by 14% and 12%, respectively, under normal walking load. No element of cortical bone in any of the models had an absolute value of principal strain that exceeded 1%. The peak von Mises stress (VMS) of the implants ranged from 260 to 289 MPa, and the highest peak VMS value was 50% lower than the yield strength of the titanium alloy (800 MPa). The longer anti-rotation screw did not affect fracture stability. CONCLUSIONS: The pre-sliding technique using the FNS showed higher fracture stability than the standard fixation technique for a Pauwels type III femoral neck fracture. The longer anti-rotation screw did not contribute significantly to fixation stability. As this finite element analysis considered the inhomogeneous mechanical property of the bone, it offered equivalent mechanical conditions to investigate the components of interest.

Trajectory of bolt and length of plate in femoral neck system determine the stability of femur neck fracture and risk of subsequent subtrochanteric fracture : a finite element analysis.

BACKGROUND: This study aimed to analyze the differences in the stability of fractures, stress distribution around the distal-most screw according to the length of the plate and the trajectory of the bolt in Pauwels type III femoral neck fracture using the femoral neck system (FNS). METHODS: Finite element models of Pauwels type III femoral neck fractures were established with surgical variations in the trajectory of the bolt (central, inferior, valgus, and varus) and length of the lateral plate (1- and 2-hole plate). The models were subsequently subjected to normal walking and stair-climbing loads. RESULTS: The screw-holding cortical bone in subtrochanter in the model with a 2-hole plate and the bolt in the inferior trajectory and the models with 1-hole or 2-hole plate and the bolt in valgus trajectory had shown greater maximum principal strain than the models with central or varus trajectories. The gap and sliding distance on the fracture surface were larger with inferior or varus trajectories of the bolt and smaller with the valgus trajectory of the bolt under both loads, compared to those of the central trajectory. CONCLUSION: For the fixation of Pauwels type III femoral neck fracture, the trajectory of the FNS bolt and the length of the plate affect the mechanical stability of the fracture and the strain of cortical bone around the distal-most screw. The surgical target should stay on the central trajectory of the bolt and the 2-hole plate's mechanical benefits did not exceed the risk.

Analysis of the Effects of COVID-19 on Hip Fractures in Korea Without Lockdown: Interrupted Time Series Analysis Using a Nationwide Cohort.

BACKGROUND: The purpose of this study was to investigate the change in the incidence rate, length of hospital stay (LOS), in-hospital mortality rate, and surgical method of hip fractures during the coronavirus disease 2019 (COVID-19) pandemic in South Korea where lockdown restrictions were not implemented. METHODS: We calculated the expected values of the incidence of hip fractures, in-hospital mortality and LOS of hip fracture patients in 2020 (COVID period) based hip fracture database of the Korean National Health Insurance Review and Assessment (HIRA) during a 9-year period from 2011 to 2019 (pre-COVID period). A generalized estimating equation model with Poisson distribution and logarithmic link function was used to estimate adjusted annual percent change (PC) of incidence rate and 95% confidence intervals (CIs). Then, we compared the annual incidence, in-hospital mortality rate and LOS in 2020 with the expected values. RESULTS: The overall incidence rate of hip fracture in 2020 was not significantly different from the expected value (PC, -5%; 95% CI, -13 to 4; P = 0.280). In women, the incidence rate of hip fracture in age groups over 70 years was smaller than the predicted value (P < 0.001). The in-hospital mortality rate was not significantly different from the expected value (PC, 5%; 95% CI, -8 to 19; P = 0.461). The mean LOS was larger than the expected value by 2% (PC, 2%; 95% CI, 1 to 3; P < 0.001). In intertrochanteric fracture, the proportion of internal fixation was smaller than the predicted value by 2% (PC, -2%; 95% CI, -3 to -1; P < 0.001), and that of hemiarthroplasty was larger than the predicted value by 8% (PC, 8%; 95% CI, 4 to 14; P < 0.001). CONCLUSIONS: In 2020, the incidence rate of hip fracture did not significantly decrease, and in-hospital mortality rate did not significantly increase compared to the expected rates, which were projected based on the HIRA hip fracture data from 2011 to 2019. Only LOS increased slightly.

Analysis of the effects of intraoperative warming devices on surgical site infection in elective hip arthroplasty using a large nationwide database.

INTRODUCTION: The aim of our study is to analyze the association of usage and type of warming device with the risk of surgical site infection (SSI) in patients who underwent hip arthroplasty, and to analyze the factors that increase the risk of SSI if the warming device is not used. MATERIALS AND METHODS: This retrospective cross-sectional study identified subjects from data of "Evaluation of the Appropriate Use of Prophylactic Antibiotics". Included patients were defined as those who underwent elective unilateral hip hemiarthroplasty or total hip arthroplasty (THA). Patients were classified into no intraoperative warming device, forced air warming devices, and devices using conduction. Multiple logistic regression analysis was conducted to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) to assess the association between warming devices and SSI. RESULTS: A total of 3945 patients met the inclusion criteria. Compared to those who received an intraoperative warming device, the odds of developing SSI were 1.9 times higher in those who did not receive intraoperative warming devices (aOR 1.9; 95% CI 1.1-3.6). The risk of SSI was 2.2 times higher with forced air warming devices compared to devices using conduction but this difference was not statistically significant (aOR 2.2; 95% CI 0.7-6.8). The risk of SSI increased in males (aOR 2.8; 95% CI 1.1-7.2), in patients under 70 years of age (aOR 4.4; 95% CI 1.6-10.4), in patients with a Charlson`s comorbidity index of 2 or higher (aOR 3.3; 95% CI 1.3-8.7), and in patients who underwent THA (aOR 3.8; 95% CI 1.7-8.3) when intraoperative warming devices were not used. CONCLUSIONS: The use of intraoperative active warming devices is highly recommended to prevent SSI during elective hip arthroplasty. In particular, male patients younger than 70 years, those with a high CCI, and those undergoing THA are at significantly increased risk of SSI if intraoperative active warming devices are not used. Intraoperative warming device using conduction is likely superior to forced air warming device, but further studies are needed to confirm this.

Analysis of Changes in Sleep Quality and Patterns after Hip Fracture Using Real Evidence of Artificial Intelligence Linked (REAL) Hip Cohort Data.

Background and Objectives: Hip fractures are commonly found in elderly patients, and often result in chronic pain and decreased physical function, as well as worsening of overall health. It is known that early surgical intervention during the acute phase and rehabilitation are important for improving clinical outcomes for these patients. However, the importance of management for improving the quality of life of these patients is becoming more emphasized. Studies on changes in sleep patterns after hip fractures are rare overseas. Therefore, the aim of this study is to investigate the prevalence of sleep disturbance in patients with hip fractures and to analyze the changes in sleep disturbance after surgery by comparing the preoperative and postoperative results. Materials and Methods: During the period from August 2022 to January 2023, patients who underwent surgical treatment for hip fractures and were recruited into the REAL Hip Cohort were selected as research subjects. The sleep survey was conducted using the Pittsburgh Sleep Quality Index (PSQI). The PSQI is composed of 18 questions, each divided into areas of sleep quality, sleep latency, duration, efficiency, disturbance, use of medication, and daytime dysfunction. Each area is scored 0-3 points and the total is 0-21. A score greater than five indicates sleep disorder. The PSQI was surveyed during hospitalization and three months after surgery for post-fracture sleep status. To analyze changes before and after the fracture, paired T-tests and chi-square tests were performed. Results: From August 2022 to January 2023, a total of 40 patients who were recruited into the REAL Hip Cohort responded to the PSQI survey. The average age was 77.4 years and 36 were female. Sleep quality worsened from 0.75 ± 1.0 before surgery to 1.4 ± 1.0 three months after surgery (p = 0.019), and sleep efficiency also worsened from 0.4 ± 0.6 to 1.4 ± 1.0 (p < 0.001). The PSQI increased from an average of 5.2 ± 2.8 before surgery to 8.2 ± 4.2 three months after surgery (p = 0.007), and the number of patients who could be diagnosed with sleep disorders also increased from 12 (40%) to 24 (60%) (p = 0.030). Conclusions: A decline in overall sleep status was observed in patients in a survey on sleep patterns three months after hip fracture. Additional management is needed to improve their sleep patterns.

Comparative Interrupted Time Series Analysis of Long-term Direct Medical Costs in Patients With Hip Fractures and a Matched Cohort: A Large-database Study.

BACKGROUND: Previous studies on medical costs in patients with hip fractures have focused on medical costs incurred for a short period after the injury. However, patients often had comorbidities before their hip fractures that would have affected medical costs even had they not sustained a fracture. Consequently, these studies may have overestimated the costs associated with hip fractures and did not characterize the duration of increased medical costs adequately. Without knowing this crucial information, it is difficult to craft thoughtful health policy to support these patients' needs. QUESTIONS/PURPOSES: (1) To compare the direct medical costs for 5 years before fracture and up to 5 years after injury in a group of patients who underwent hip fracture surgery with a matched group of patients who did not experience a hip fracture, (2) to analyze the duration over which the increased direct medical costs associated with a hip fracture continues, and (3) to analyze whether there is a difference in direct medical costs according to age group using a nationwide claims database in South Korea. METHODS: The National Health Insurance Service Sample cohort in South Korea consisted of 1 million patients who were selected using a systematic, stratified, random sampling method from 48,222,537 individuals on December 31, 2006. Under a compulsory social insurance system established by the National Health Insurance Act, all patients were followed until 2015. Patients with hip fractures and matched controls were selected from the National Health Insurance Service sample of South Korea. Patients with hip fractures were defined as those who were hospitalized with a diagnosis of femoral neck fracture or intertrochanteric fracture and who underwent surgical treatment. We excluded patients with hip fractures before January 1, 2007 to ensure a minimum 5-year period that was free of hip fractures. Patients with hip fractures were matched with patients of the same age and gender at the date of admission to an acute care hospital for surgery (time zero). If patients with hip fractures died during the follow-up period, we performed matching among patients whose difference from the time of death was within 1 month. This method of risk-set matching was repeated sequentially for the next patient until the last patient with a hip fracture was matched. We then sequentially performed 1:5 random sampling for each risk set. A total of 3583 patients in the hip fracture cohort (patients with hip fractures) and 17,915 patients in the matched cohort (those without hip fractures) were included in this study. The mean age was 76 ± 9 years, and 70% were women in both groups. Based on the Charlson comorbidity index score, medication, and medical history, the patients with hip fractures had more comorbidities. Person-level direct medical costs per quarter were calculated for 5 years before time zero and up to 5 years after time zero. Direct medical costs were defined as the sum of that insurer's payments (that is, the National Health Insurance Service's payments), and that patient's copayments, excluding uncovered payments. We compared direct medical costs between patients with hip fractures and the patients in the matched cohort using a comparative interrupted time series analysis. The difference-in-difference estimate is the ratio of the differences in direct medical costs before and after time zero in the hip fracture cohort to the difference in direct medical costs before and after time zero in the matched cohort; the difference in difference estimates were calculated each year after injury. To identify changes in direct medical cost trends in patients with hip fractures and all subgroups, joinpoint regression was estimated using statistical software. RESULTS: The direct medical costs for the patients with hip fractures were higher than those for patients in the matched cohort at every year during the observation period. The difference in direct medical costs between the groups before time zero has increased every year. The direct medical costs in patients with hip fractures was the highest in the first quarter after time zero. Considering the differential changes in direct medical costs before and after time zero, hip fractures incurred additional direct medical costs of USD 2514 (95% CI 2423 to 2606; p < 0.01) per patient and USD 264 (95% CI 166 to 361; p < 0.01) per patient in the first and second years, respectively. The increase in direct medical costs attributable to hip fracture was observed for 1.5 to 2 years (difference-in-difference estimate at 1 year 3.0 [95% CI 2.8 to 3.2]; p < 0.01) (difference-in-difference estimate at 2 years 1.2 [95% CI 1.1 to 1.3]; p < 0.01; joinpoint 1.5 year). In the subgroups of patients younger than 65, patients between 65 and 85, and patients older than 85 years of age, the increase in direct medical costs attributable to hip fracture continued up to 1 year (difference-in-difference estimate ratio at 1 year 2.7 [95% CI 2.1 to 3.4]; p < 0.01; joinpoint 1 year), 1.5 to 2 years (difference-in-difference estimate ratio at 1 year 2.8 [95% CI 2.6 to 3.1]; p < 0.01; difference-in-difference estimate ratio at 2 years 1.2 [95% CI 1.1 to 1.3]; p < 0.01; joinpoint 1.5 years), and 39 months to 5 years (difference-in-difference estimate ratio at 1 year 5.2 [95% CI 4.4 to 6.2]; p < 0.01; difference-in-difference estimate ratio at 5 years 2.1 [95% CI 1.4 to 3.1]; p < 0.01; joinpoint 39 months) from time zero, respectively. CONCLUSION: The direct medical costs in patients with hip fractures were higher than those in the matched cohort every year during the 5 years before and after hip fracture. The increase in direct medical costs because of hip fractures was maintained for 1.5 to 2 years and was greater in older patients. Based on this, we suggest that health policies should focus on patients' financial and social needs, with particular emphasis on the first 2 years after hip fracture with stratification based on patients' ages. LEVEL OF EVIDENCE: Level II, economic analysis.

Do Cementless Short Tapered Stems Reduce the Incidence of Thigh Pain After Hip Arthroplasty? Systematic Review and Meta-Analysis.

BACKGROUND: The purpose of this study was to determine whether short tapered stems reduce the rate of thigh pain through a systematic review and meta-analysis of comparative studies between short tapered stems and standard-length tapered stems. METHODS: We conducted a meta-analysis of comparative studies: 1) retrospective studies and 2) randomized controlled trials (RCTs), on 2 stem designs: short tapered stem versus standard-length tapered stem. Studies were selected by means of the following criteria: 1) study design: retrospective comparative studies, prospective comparative studies, RCTs; 2) study population: patients with total hip arthroplasty or hemiarthroplasty for hip disease or hip fracture; 3) intervention: short tapered stem and standard tapered stem; and 4) outcomes; thigh pain, other clinical results. RESULTS: Among the 250 articles that were identified at the initial search, 6 studies, 4 RCTs and 2 retrospective comparative studies, were included in this meta-analysis. In the analysis of retrospective studies, the short tapered stem reduced the risk of thigh pain compared to the standard tapered stem (risk ratio [RR] = 0.13; 95% confidence interval [CI], 0.02-0.09; Z = -2.07; P = 0.039). However, in the analysis of RCTs, the incidence of thigh pain was similar between the two stem designs (RR = 1.21; 95% CI, 0.76-1.93; Z = 0.82; P = 0.410). Overall meta-analysis including all studies showed that the short tapered stem did not reduce the incidence of thigh pain compared to the standard-length tapered stem (RR = 0.91; 95% CI, 0.59-1.40; Z = -0.44, P = 0.663). CONCLUSIONS: We did not find a significant difference in the incidence of thigh pain between short tapered stem and standard tapered stem in hip arthroplasty. TRIAL REGISTRATION: PROSPERO Identifier: CRD42021231240.

Relationship between pressure ulcer risk and sarcopenia in patients with hip fractures.

OBJECTIVE: Pressure ulcer (PU) is a frequent complication of hip fractures. PUs can develop at any time after a hip fracture but most appear within 2-4 days after surgery. The purpose of this study was to investigate the association between hip fractures due to sarcopenia and the risk of PUs in patients with hip fracture. METHOD: Between March 2017 and March 2019, patients aged ≥65 years of age with hip fractures were included in this retrospective cohort study. PU risk assessment according to the Braden Scale was performed within the first few hours after arrival at hospital. Skeletal muscle mass index (SMI) and hand grip strength were evaluated for a diagnosis of sarcopenia. RESULTS: Of the 289 patients admitted to the study institution, 180 patients were finally enrolled in the study (129 females; 51 males). In male patients, as SMI increased, so too did the Braden Scale score, which was statistically significant (p=0.02). However, there was no statistically significant difference between SMIs and Braden Scale scores in female patients (p=0.304). In male patients, there was no statistically significant difference between hand grip strength and Braden Scale score (p=0.251). However, in female patients, as hand grip strength increased, so too did the Braden Scale score; this was also statistically significant (p=0.041). CONCLUSION: In this study, decreased muscle mass and muscle weakness in patients with hip fractures were associated with increased PU risk as measured by Braden Scale scores in both males and females.

Association between antidepressants, benzodiazepine and all-cause mortality in elderly hip fracture: A Korean nationwide cohort study.

BACKGROUND: The purpose of this study was to analyze the association between the preoperative and postoperative use of antidepressant and benzodiazepine and all-cause mortality in elderly hip fracture patients. METHODS: Patients who underwent surgical treatment for hip fracture over 65 years old were classified into Past-user, Current-user, and Non-users for each period according to use history for antidepressants or benzodiazepines. And, for the subgroup analysis, patients were classified by presence of past history for psychiatric medication. A multivariable-adjusted Cox proportional hazards model was used to investigate the effects of antidepressants and benzodiazepines on all-cause mortality. RESULTS: A total of 15,576 patients were included in this study. Past users of antidepressants and benzodiazepines were 5699 (36.59%) patients and 11,319 (72.67%) patients, respectively. Current users of antidepressants and benzodiazepines were 2888 (18.54%) patients and 6287 (40.36%) patients, respectively. There were no statistically significant differences in the adjusted hazard for death compared to the non-users for both the past and the current users (p > 0.05). In the subgroup analysis, there were 12,502 once-users and 3074 never-users according to psychiatric medication. Current uses of antidepressants and benzodiazepine in the once-user did not increase adjusted hazard for death compared to the non-users (p>0.05). However, current uses of antidepressants by never-users increased the adjusted hazard for death compared to the non-user (adjusted hazard ratio, 1.31; 95% CI, 1.08-1.59; p = 0.007). CONCLUSIONS: No association was observed between the uses of antidepressants and benzodiazepines after hip fracture and mortality risk in elderly patients who received psychiatric medication before hip fracture. However, the use of these medications was associated with increased all-cause mortality risk in patients who had no history of psychiatric medication before hip fracture. LEVEL OF EVIDENCE: III, retrospective cohort study.

Comparison of hip structure analysis and grip strength between femoral neck and basicervical fractures.

BACKGROUND: The purpose of this study was to analyze differences in geometrical properties of the proximal femur and predict the occurrence of basicervical fractures through a comparative study of femoral neck and basicervical fractures in patients undergoing hip structural analysis (HSA). METHODS: All patients with hip fractures who were at least 65 years old and admitted to our hospital between March 2017 and December 2019 were eligible for this study. During the study period, 149 femur neck fractures (FNF) and basicervical fractures (intertrochanteric fractures of A31.2) were included in this study. Fifty-nine patients were included in the final analysis. Factors considered to be important confounders affecting the occurrence of basicervical hip fractures were chosen for propensity-score analysis. A logistic model with basicervical hip fracture as the outcome and age, sex, weight, spinal T-score, hip T-score, and vitamin D levels as confounders was used to estimate the propensity score. RESULTS: The cross-sectional moment of inertia (CSMI) of the intertrochanter was significantly lower in patients with basicervical hip fracture (HF) than in patients with FNF (p = 0.045). However, there was no significant differences in any other HSA variable between the two groups. Receiver operating characteristic (ROC) analysis showed that cutoff point for HSA was 100 for hip axis length (HAL) (AUC = 0.659, p < 0.001) and 5.712 for CSMI of the intertrochanter (AUC = 0.676, p < 0.001). ROC analysis showed that cutoff points of HAL, CSMI of intertrochanter, and handgrip strength were 104.8, 8.75, and 16.9, respectively (AUC = 0.726, p < 0.001). CONCLUSIONS: Proximal femoral geometric analysis using HSA is a useful method for predicting the type of hip fracture. Additionally, a lower CSMI, a shorter HAL, and a lower grip strength are major predictors of basicervical fractures.

Improved control over implant anchorage under the use of the femoral neck system for fixation of femoral neck fractures: a technical note.

BACKGROUND: The depth of bolt in Femoral neck system (FNS, DePuy Synthes, Oberdorf, Switzerland) is difficult to finely control as the length of the bolt is in units of 5 mm. Thus, this study introduces a method to control the depth of FNS bolt in analogue scale in patients with femoral neck fracture. METHODS: By the technique of control of reaming and retraction of bolt, the tip of implant could be positioned close to subchondral bone without harming it. The position of implant tip in four cases in which the introduced technique was applied was compared to that of eight cases where the standard technique was performed. RESULTS: The average tip-apex distance measured in the cases that underwent surgery using the suggested technique in this study was statistically significantly shorter than that measured in the cases that underwent surgery under manufacturer guidelines. CONCLUSION: Even though the bolt of FNS is manufactured in the unit of 5 mm, the technique proposed in this study helps surgeons to adjust the depth of bolt for the fixation of femoral neck fracture using FNS.

Effect of Opioids on All-cause Mortality and Opioid Addiction in Total Hip Arthroplasty: a Korea Nationwide Cohort Study.

BACKGROUND: The purpose of this study was to investigate the use of opioids before and after total hip arthroplasty (THA), to find out the effect of opioid use on mortality in patients with THA, and to analyze whether preoperative opioid use is a risk factor for sustained opioid use after surgery using Korean nationwide cohort data. METHODS: This retrospective nationwide study identified subjects from the Korean National Health Insurance Service-Sample cohort (NHIS-Sample) compiled by the Korean NHIS. The index date (time zero) was defined as 90 days after an admission to a hospital to fulfill the eligibility criteria of the THA. RESULTS: In the comparison of death risk according to current use and the defined daily dose of tramadol and strong opioids in each patient group according to past opioid use, there were no statistically significant differences in the adjusted hazard ratio for death compared to the current non-users in all groups (P > 0.05). Past tramadol and strong opioid use in current users increased the risk of the sustained use of tramadol and strong opioids 1.45-fold (adjusted rate ratio [aRR]; 95% confidence interval [CI], 1.12-1.87; P = 0.004) and 1.65-fold (aRR; 95% CI, 1.43-1.91; P < 0.001), respectively, compared to past non-users. CONCLUSION: In THA patients, the use of opioids within 6 months before surgery and within 3 months after surgery does not affect postoperative mortality, but a past-use history of opioid is a risk factor for sustained opioid use. Even after THA, the use of strong opioids is observed to increase compared to before surgery.

Effect of Dementia on Postoperative Mortality in Elderly Patients with Hip Fracture.

BACKGROUND: The aim of this study was to assess the prevalence of dementia as an underlying disease in elderly patients with hip fracture, to investigate the effect of dementia on postoperative mortality after surgery of hip fracture, and to analyze the differences in postoperative mortalities according to the severity of dementia through subgroup analysis. METHODS: This study selected 2,346 elderly patients who were diagnosed with unilateral intertrochanteric or femoral neck fractures who underwent surgery between January 2004 and December 2018. The patients were classified into the non-dementia group (2,196 patients) and dementia group (150 patients; no-medication [66 patients] and medication [84 patients] subgroups). The cumulative crude mortality rate was calculated, and 30-day, 60-day, 3-month, 6-month, and 1-year mortality rates were compared between the groups. A univariate regression test was performed using age, sex, diagnosis, surgery type, and Charlson's comorbidity index (CCI), as these variables had P values of < 0.10. Multivariate regression analysis was performed to identify independent risk factors associated with mortality. RESULTS: The 30-day, 60-day, 3-month, 6-month, and 1-year postoperative cumulative mortality rates were 1.8%, 3.8%, 5.6%, 8.9%, and 13.6%, respectively, in the non-dementia group, and 2%, 7.3%, 14%, 19.3%, and 24%, respectively, in the dementia group (P = 0.748, P = 0.048, P < 0.001, P < 0.001, and P = 0.001). The factors that affected the 1-year mortality were age (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.02-1.08; P < 0.001), sex (OR, 2.68; 95% CI, 2.07-3.47; P < 0.001), CCI (OR, 1.34; 95% CI, 1.23-1.47; P < 0.001), and dementia (OR, 1.70; 95% CI, 1.46-1.08; P = 0.016). In subgroup analysis, severity of dementia influenced the 6-month mortality (OR, 1.41; 95% CI, 1.70-2.01; P = 0.018), and 1-year mortality (OR, 1.30; 95% CI, 1.17-1.90; P = 0.027). CONCLUSION: In elderly hip fracture patients, the comparison between patients with and without dementia revealed that dementia was an independent risk factor for mortality at a minimum of 1 year of follow-up, and the severity of dementia in hip fracture patients was a risk factor for mortality within 6 months and 1 year, postoperatively.

Comparison of Mortality, Length of Hospital Stay and Transfusion between Hemiarthroplasty and Total Hip Arthroplasty in Octo- and Nonagenarian Patients with Femoral Neck Fracture: a Nationwide Study in Korea.

BACKGROUND: The purpose of this study was to compare the mortality rate between patients undergoing hemiarthroplasty (HA) and those undergoing total hip arthroplasty (THA) in two age groups: patients aged 65-79 years (non-octogenerian) and patients aged ≥ 80 years (octogenarian). METHODS: We identified elderly (aged ≥ 65 years) femoral neck fracture patients who underwent primary THA or HA from January 1, 2005 to December 31, 2015 in South Korea using the Health Insurance and Review and Assessment database; the nationwide medical claim system of South Korea. We separately compared the mortality rate between the HA group and THA group in two age groups. A generalized estimating equation model with Poisson distribution and logarithmic link function was used to calculate the adjusted risk ratio (aRR) of death according to the type of surgery. RESULTS: The 3,015 HA patients and 213 THA patients in younger elderly group, and 2,989 HA patients and 96 THA patients in older elderly group were included. In the younger elderly group, the mortality rates were similar between the two groups. In older elderly group, the aRR of death in the THA group compared to the HA group was 2.16 (95% confidence interval [CI], 1.20-3.87; P = 0.010) within the in-hospital period, 3.57 (95% CI, 2.00-6.40; P < 0.001) within 30-days, and 1.96 (95% CI, 1.21-3.18; P = 0.006) within 60-days. CONCLUSIONS: In patients older than 80 years, THA was associated with higher postoperative mortality compared to HA. We recommend the use of HA rather than THA in these patients.

Population-based Analysis for Risk of Suicide Death in Elderly Patients after Osteoporotic Fracture: a Nested Case-Control Study.

BACKGROUND: The purpose of study was to investigate the incidence rate of suicide in elderly patients with osteoporotic fractures in a nested case-control model and to analyze the change in the risk of suicide death over time after each osteoporotic fracture. METHODS: We used the National Health Insurance Service-Senior cohort of South Korea. Suicide cases and controls were matched based on sex and age at the index date. Controls were randomly selected at a 1:5 ratio from the set of individuals who were at risk of becoming a case at the time when suicide cases were selected. Conditional logistic regression analysis was performed to evaluate the association between each type of osteoporotic fracture and the risk of suicide death. RESULTS: Three thousand seventy suicide cases and 15,350 controls were identified. Patients with hip fracture showed an increased risk of suicide death within 1 year of fracture (adjusted odds ratio [aOR] = 2.64; 95% confidence interval [CI], 1.57-4.46; P < 0.001) compared to controls. However, the increased risk of suicide death in patients with hip fracture lasted up to 2 years (aOR = 1.59; 95% CI, 1.04-2.41; P = 0.031). Spine fracture increased the risk of suicide deaths for all observation periods. There was no evidence that humerus fracture increased the risk of suicide death during the observational period. Radius fracture increased only the risk of suicide death within 2 years of fracture (aOR = 1.43; 95% CI, 0.74-2.77; P = 0.282). CONCLUSION: There were noticeable differences in both degree and duration of increased suicide risks depending on the type of osteoporotic fracture. Mental stress and suicide risk in elderly patients after osteoporotic fracture should be assessed differently depending on the types of fracture.

Effect of Opioids on All-cause Mortality and Sustained Opioid Use in Elderly Patients with Hip Fracture: a Korea Nationwide Cohort Study.

BACKGROUND: The purpose of our study was to assess the use of opioids before and after hip fracture in elderly patients in order to determine the effect of opioid use on all-cause mortality, and to analyze how the history of opioid use before fracture increases the risk of sustained use following hip fracture using a Korea nationwide cohort. METHODS: Our study identified hip fracture patients from the Korean National Health Insurance Service-Senior cohort. The index date was defined as 90-days after admission to the acute care hospital that fulfilled the eligibility criteria of elderly hip fracture. Patients were classified into past user, current user, and sustained user according to the use of opioid at each period based on the time of admission and index date. The opioids were classified into strong opioids and tramadol. A generalized estimating equation model with a Poisson distribution and logarithmic link function was performed to estimate the adjusted rate ratios (aRRs) and 95% confidence intervals (CIs) to assess the association between past use and sustained use. A multivariable-adjusted Cox proportional hazard model was used to investigate the effects of strong opioid and tramadol use on all-cause mortality. RESULTS: A total of 12,927 patients were included in our study. There were 7,384 (57.12%) opioid past-users, 11,467 (88.71%) opioid current-users, and 7,172 (55.48%) sustained users. In comparison of the death risk according to current use or the defined daily dose of the opioids or past opioid use, there were no significant differences in the adjusted hazard ratio for death in all groups, compared to the current non-users (P > 0.05). Among survivors 1 year after hip fracture, opioid past-use increased the risk of opioid sustained use by 1.52-fold (aRR; 95% CI, 1.45-1.8; P < 0.001). CONCLUSION: Current use and past use of opioid did not increase all-cause mortality after hip fracture in elderly patients over 65 years of age. Past use of opioid before hip fracture increased risk of sustained use of opioid compared to the current opioid used without past use.

What Is the Difference in the Risk of Suicide Death Between Spine Fracture in Patients Older Than 65 Years and Matched Controls? A Large-database Study from South Korea.

BACKGROUND: Pain and kyphotic deformity after spinal fractures can result in a decrease in a patient's physical function and quality of life. Furthermore, physical illness, such as respiratory compromise, or mental illness, including depression, may be exacerbated by a spinal fracture. Complications caused by spinal fractures and old age are risk factors for suicide, but studies on these patients are rare. QUESTIONS/PURPOSES: (1) What is the incidence rate of death by suicide after a spinal fracture in patients older than 65 years? (2) How much does the risk of death by suicide increase in patients older than 65 years who have spine fractures compared with well-matched controls? (3) How does this risk change as a function of increasing time after injury? METHODS: Spinal fractures in patients older than 65 years and matched controls were selected from the National Health Insurance Service-Senior cohort (NHIS-Senior) of South Korea. The NHIS-Senior consists of 558,147 people selected by 10% simple random sampling method from a total of 5.5 million people 60 and older in 2002; all people were followed through 2015. A total of 31,357 patients with spine fractures and their 62,714 matched controls remained in the study. The mean follow-up time was 4.3 ± 3.0 years (135,229 person-years) in the spine fracture group and 4.6 ± 3.0 years (290,096 person-years) in the matched control group. We matched the groups for demographic factors such as age, gender, Charlson Comorbidity Index score, medication history, medical history, preoperative disability, number of hospital admissions, as well as socioeconomic factors such as household income level, residential district, and type of national health insurance using a 1:2 risk set propensity score matching by a nearest-neighbor matching algorithm with a maximum caliber of 0.1 of the hazard components. The incidence rate of suicide and the 95% confidence interval were calculated based on a generalized linear model with a Poisson distribution. The effect size was presented as a hazard ratio (HR) using Cox's proportional hazard model with robust variance estimator that accounts for clustering within matched pairs. RESULTS: The overall risk of death by suicide throughout the surveillance period, expressed as an incidence rate, was 116 per 100,000 person-years in spinal fracture (157 deaths by suicide over 135,229 person-years). Throughout the entire surveillance period, the risk of death by suicide was greater among patients with spinal fractures than it was in the control group (HR 1.8 [95% CI 1.5 to 2.2]; p < 0.01). This difference was greatest in the first 365 days after the fracture (HR 2.5 [95% CI 1.6 to 3.8]; p < 0.01) (45 deaths by suicide, incidence rate: 156 per 100,000 person-years in spinal fracture). The risk of suicide death in patients with spine fracture from 365 days to the last follow-up was also higher than that of matched controls (HR 1.6 [95% CI 1.3 to 2.1]; p < 0.01). CONCLUSIONS: Considering the substantially increased risk of death by suicide in patients with spine fractures who are older than 65 years, surgeons should consider offering psychiatric evaluation and management more frequently, particularly in patients with chronic pain, functional disability, and depressive mood. Future studies should investigate the underlying causes of suicide, such as deteriorating socioeconomic support or depression, and whether early initiation of psychological support after injury can reduce the suicide rate. LEVEL OF EVIDENCE: Level III, prognostic study.

The Influence of Renal Dialysis on All-Cause Mortality in Older Patients with Hip Fracture: a Korean Nationwide Cohort Study.

BACKGROUND: The purpose of this study was to analyze the all-cause mortality rate over time after elderly hip fracture in end-stage renal disease (ESRD) patients with dialysis, using a Korean nationwide claims database. METHODS: This retrospective nationwide study identified subjects from the Korean National Health Insurance Service-Senior cohort (NHIS-Senior). The NHIS-Senior (total of 588,147 participants) was constructed by 10% random sampling and was designed to represent the elderly living in Korea. Subjects were patients aged 65-99 years who underwent surgical treatment for femoral neck fractures or intertrochanteric fractures. A generalized estimating equation model with Poisson distribution and logarithmic link function was used to estimate adjusted risk ratios (aRRs) and 95% confidence intervals (CIs) to measure associations between renal dialysis and cumulative mortality in various time frames. RESULTS: The total number of patients included in this study was 16,818. These patients were divided into two groups: 116 (0.69%) in the dialysis group and 16,702 (99.31%) in the no-dialysis group. The mean length of hospital stay was 43.87 ± 48.45 days in the dialysis group and 36.29 ± 37.49 days in the no-dialysis group (P = 0.095). The effect of renal dialysis on all-cause mortality was 2.29-fold (aRR; 95% CI, 1.29-4.06; P = 0.005) within 30 days and 1.72-fold (aRR; 95% CI, 1.34-2.21; P < 0.001) within 1-year after hip fracture compared to the no-dialysis group. And, the effect of renal dialysis of in-hospital mortality was 2.72-fold (aRR; 95% CI, 1.71-4.33; P < 0.001) compared to the no-dialysis group. CONCLUSION: Elderly patients who underwent dialysis have very high mortality rates after hip fracture. Therefore, it is considered that postoperative care through multidisciplinary management and understanding of pathophysiology for the ESRD patients is necessary.