In-Hospital Hip Fractures in a Large Irish Teaching Hospital: Patient Risk Factors and Outcomes.

INTRODUCTION: In-hospital hip fractures follow falls during unrelated admissions. Little data in the Irish setting is available on this vulnerable subset of hip fracture patients. Our objective is to review the incidence of in-hospital hip fractures, identify risk factors, and evaluate outcomes. METHODS: This is a retrospective observational review. We collected patient data in St. James' Hospital using the Hospital In-Patient Enquiry database and Electronic Patient Records for in-hospital hip fractures between 10/02/2017 and 22/04/2020. Comorbidity, survival, and discharge destination data were gathered. RESULTS: We identified 40 fractures, representing 11.5% of all hip fractures treated at our center during the study period. The patients were 60-95 years old. Median age was 77 years for males and 86 years for females. Most (72.5%) were identified as fall risks, and 52% were unwitnessed falls. Many had a history of falls (67.5%), dementia (52.5%), or both (42.5%). Delirium was common (42.5%), and 75% had at least one vascular/coagulation disorder. Mortality was 10.25% at 30 days, 23.1% at 90 days, and 51.4% at 12 months. Although 70% were admitted from home, only 10% were discharged back home. 30% were admitted to a nursing home, and 55% were discharged from a nursing home. CONCLUSION: In-hospital hip fractures accounted for 11.5% of all hip fractures treated at our center, confirming the need for a well-defined hospital protocol. Patients often present with previous falls, dementia, and cardiovascular disease. Outcomes are poor, with 51.4% mortality at 12 months and significant morbidity reflected by a loss of independent living.

Readability of Patient Educational Materials in Sports Medicine.

Background: The internet has become an increasingly popular resource among sports medicine patients seeking injury-related information. Numerous organizations recommend that patient educational materials (PEMs) should not exceed sixth-grade reading level. Despite this, studies have consistently shown the reading grade level (RGL) of PEMs to be too demanding across a range of surgical specialties. Purpose: To determine the readability of online sports medicine PEMs. Study Design: Cross-sectional study. Methods: The readability of 363 articles pertaining to sports medicine from 5 leading North American websites was assessed using 8 readability formulas: Flesch-Kincaid Reading Grade Level, Flesch Reading Ease Score, Raygor Estimate, Fry Readability Formula, Simple Measure of Gobbledygook, Coleman-Liau Index, FORCAST Readability Formula, and Gunning Fog Index. The mean RGL of each article was compared with the sixth- and eighth-grade reading level in the United States. The cumulative mean website RGL was also compared among individual websites. Results: The overall cumulative mean RGL was 12.2 (range, 7.0-17.7). No article (0%) was written at a sixth-grade reading level, and only 3 articles (0.8%) were written at or below the eighth-grade reading level. The overall cumulative mean RGL was significantly higher than the sixth-grade [95% CI for the difference, 6.0-6.5; P < .001] and eighth-grade (95% CI, 4.0-4.5; P < .001) reading levels. There was a significant difference among the cumulative mean RGLs of the 5 websites assessed. Conclusion: Sports medicine PEMs produced by leading North American specialty websites have readability scores that are above the recommended levels. Given the increasing preference of patients for online health care materials, the imperative role of health literacy in patient outcomes, and the growing body of online resources, significant work needs to be undertaken to improve the readability of these materials.

Perioperative haematological outcomes following total knee arthroplasty in haemophiliacs.

PURPOSE: Patients with haemophilia suffer from recurrent joint haemarthrosis. This can progress to symptomatic arthropathy commonly affecting the knee. While modern coagulation strategies have reduced those proceeding to end-stage arthropathy, total knee arthroplasty (TKA) remains the optimal treatment for some patients. Despite innovation in perioperative haematological management, concerns about the potential for excessive haemorrhage still exist. The aim of this study is to quantify immediate postoperative blood loss and haematological complications in haemophiliacs following TKA. METHODS: A retrospective study of patients with haemophilia types A or B who underwent a TKA over a 12-year period at a single institution was conducted. These patients were compared to both a non-haemophiliac control group and to published standards in non-haemophiliacs undergoing TKA. RESULTS: Twenty-one TKA procedures in 18 patients (72% haemophilia A, 28% haemophilia B) were suitable for inclusion with a mean age of 44 years. The mean haemoglobin drops at 24 and 48 h postoperatively were 2.7 g/dl and 3.8 g/dl respectively. There was no significant difference in haemoglobin drop at 48 h postoperatively when compared to the non-haemophiliac control group (P = 0.2644). There were no immediate perioperative complications and two patients (9.6%) required postoperative transfusion. CONCLUSION: Haemophiliacs undergoing a unilateral primary TKA in a specialised tertiary referral centre appear to have comparable rates of perioperative blood loss when compared to both a non-haemophiliac control group as and published haemostatic standards in non-haemophiliac patients following TKA. Perioperative management with expert orthopaedic and haematological input is recommended to optimise outcomes in this complex patient group.

Knee osteotomy: Quality tools and readability data of information on the internet.

Supplementary data for the article Osteotomy around the Knee: Assessment of Quality, Content and Readability of Online Information is provided. 45 unique websites were evaluated. The DISCERN score, JAMA (Journal of the American Medical Association) benchmark criteria and HONcode (Health On the Net) criteria are provided for reference. Readability of online information was analysed with Readability Studio Professional Edition, Version 2019 (Oleander Software Ltd.). The software assessed readability using eight different instruments: Flesch-Kincaid Reading Grade Level (FKGL), Flesch Reading Ease Score (FRES), Raygor Estimate, SMOG, Coleman- Liau, Fry, FORCAST and Gunning Fog. Data is also provided on the percentage of complex words, long words, Dale-Chall unfamiliar words, Fog words, as well as the number of 'wordy' items, overly long sentences and longest sentence length.

Osteotomy around the knee: Assessment of quality, content and readability of online information.

BACKGROUND: As knee osteotomy surgery becomes increasingly accessible, more patients may turn to the Internet for information. This study examined the source, quality, content and readability of online information regarding osteotomy around the knee. METHODS: The first 70 websites returned by the top four search engines were identified using the key words: "knee osteotomy" and "high tibial osteotomy." The websites were categorised by type and assessed using the DISCERN score, Journal of the American Medical Association (JAMA) benchmark criteria and a novel Knee Osteotomy-Specific Score (KOSS). The presence of the Health On the Net (HON) code accreditation seal was noted. Readability of each website was assessed using eight readability formulae. The mean reading grade level (RGL) was compared to the 6th and 8th grade reading levels. The mean RGL of each category was also compared. RESULTS: Of the 45 unique websites analysed, the majority were Physician (33%) and Journal websites (31%). The mean DISCERN score was 36.7 (±8.9) which is classified as 'poor.' The mean JAMA benchmark criteria score was 2.04 (±1.5) and Physician websites were most likely to be scored zero. The mean KOSS was 15.4 (±5.7). The highest scoring website was a Commercial site but, overall, Journal category sites provided the best quality information. Websites that bore the HONcode seal obtained higher DISCERN, JAMA benchmark criteria and Knee Osteotomy - Specific Scores. The cumulative mean RGL was 13.2 (±2.2) which exceeded the 6th grade level by an average of 7.2 grade levels and the 8th grade level by an average of 5.2 grade levels. No website (0%) was written at or below either the 6th or the 8th grade reading levels. The mean Flesch Reading Ease Score of all websites was 41.13 (±14.7) which is classified as 'difficult.' Journal websites had the highest RGL. CONCLUSION: The information available online regarding osteotomy around the knee varies tremendously in quality and completeness. Physician sites predominate, but these were among the lowest scoring of all websites. Even where high quality information is available, it is set at too high a level to be easily understood. LEVEL OF EVIDENCE: Survey of materials - Internet.

Incidence of Non-Simultaneous Contralateral Second Hip Fractures: A Single-Center Irish Study.

Introduction Hip fractures are a significant cause of morbidity and mortality in the elderly and are also associated with increased healthcare costs. A second contralateral hip fracture can lead to even more complications and healthcare costs. A significant proportion of the Irish hip fracture population does not receive a bone health assessment or falls specialist assessment to reduce the risk of future falls and fractures. This study aimed to analyze the incidence of a non-simultaneous contralateral hip fracture in an Irish population. Methods We retrospectively analyzed 1,344 patients presenting to our institution with a hip fracture from January 2007 to June 2019. Patients aged ≥ 60 years old presenting with a neck of femur or pertrochanteric fracture were included in our study. We excluded patients who had sub-trochanteric and femoral shaft fractures, high energy fractures, and pathological fractures. We also excluded patients less than 60 years old, as fractures in these younger patients may not be purely related to osteoporosis. Results A total of 1,099 hip fractures meeting the inclusion criteria were treated at our unit during the designated time period. A total of 102 (9.3%) patients experienced a second hip fracture. The mean age at first presentation in our institution was 78.5 years old, with a mean time between first and second hip fractures of 37.2 months. Conclusions Patients presenting with a second hip fracture may represent 9.3% of the Irish hip fracture population. We hope that this study will help inform on the rate of second hip fractures in an Irish population and help advocate for improved resources and implementation of secondary prevention strategies.

Skin Puckering in a Tibial Fracture.

Skin puckering is a feature observed in fractures that undergo large displacements at the time of initial injury and occur as a result of adherence of the dermal tissues to the underlying fracture fragment. Herein, we discuss the interesting case of a 47-year-old male who suffered a comminuted tibial shaft fracture which resulted in marked pretibial skin puckering prior to fracture reduction with striking corresponding images noted on computerised tomography (CT) scanning.

Predisposing Factors and Outcomes After Prolonged Admission Following Hip Fracture.

Introduction Hip fractures are increasingly prevalent and can result in substantial morbidity, mortality, and cost. Despite the existence of enhanced management strategies, prolonged hip fracture admissions persist. This study's objective was to ascertain characteristics associated with a prolonged length of stay (LOS) and quantify return to baseline once discharged. Methods A retrospective audit of hip fractures over a four-year period was conducted, identifying patients with a LOS over 100 days. Demographics, comorbidities, pre- and post-admission function, and status were assessed. Patients sustaining inpatient hip fractures were excluded to negate the effect of initial admission on LOS. Results Seven hundred and eleven hip fractures were treated, of which 48 (6.8%) were suitable for inclusion. The patients' median age and LOS was 83.5 years and 153 days, respectively. Preoperative American Society of Anesthesiologists - Physical Status (ASA-PS) Grades II and III predominated at 41.7% and 39.6%, respectively. Eighteen of patients had a diagnosis of dementia before admission, increasing to 29 on discharge (P = 0.0026). One patient was in long-term care prior to admission, rising to 30 on discharge (P < 0.0001), with only 25.6% returning to pre-admission residential status (P < 0.0001). Nineteen patients were mobilising unaided prior to admission, decreasing to only two following discharge, with a mere 37.1% returning to their pre-admission mobility baseline (P < 0.0001). Discussion Hip fracture patients with multiple comorbidities or a diagnosis of dementia were most likely to have a prolonged LOS which, in turn, impacted upon return to baseline mobility, cognitive status, and independence. Early identification and management of this cohort may help reduce the potential disease burden and economic effects that a prolonged LOS creates.

Single versus separate implant fixation for concomitant ipsilateral femoral neck and shaft fractures: A systematic review.

Concomitant ipsilateral femoral neck and shaft fractures are uncommon, occurring in 1-9% of femoral shaft fractures. While this injury typically occurs in young patients following high-energy trauma, little consensus has been established regarding the optimal fixation approach. A multitude of treatment strategies exist, with limited evidence as to which is more favorable. The aim of this study was to appraise current evidence, comparing management with either one single or separate devices for both fractures. A systematic review was undertaken in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies published between 1992 and 2018 comparing the rate of postoperative nonunion, malunion, delayed union, avascular necrosis, infection or reoperation between at least one method of single device fixation and one method of separate device fixation were included. Six non-randomized cohort studies assessing 173 patients were suitable for inclusion, each comparing single device cephalomedullary nail fixation of both fractures with a combination of devices. All patients presented following high-energy trauma, at a median age of 32 years. While low complication rate and favorable outcomes were found across both groups, no significant difference could be inferred between either treatment strategy. This injury continues to occur in the traditionally described patient group, and results in acceptable postoperative outcomes. A paucity of randomized studies limits the ability to recommend a single or separate device treatment approach, and as such prospective, randomized trials with adequately powered sample sizes are required to definitively compare surgical management strategies in this rare but complex injury.

Diagnosis of human immunodeficiency virus following femoral head harvest post-total hip arthroplasty.

Elective total hip arthroplasty (THA) is a routine procedure. Intraoperative harvesting of excised femoral heads for the purpose of donation during this procedure has become standard practice, in response to increasing bone allograft demand. Robust patient screening and femoral head analysis typically occurs, to minimize the risk of disease transmission to any potential recipient. Screening for human immunodeficiency virus (HIV), a virus normally first diagnosed through serological testing, makes up part of this process. This case describes a 43-year-old male who underwent elective THA, with subsequent analysis of the excised femoral head at time of screening revealing a diagnosis of HIV, a condition previously never detected in the donor. First diagnosis of HIV from bone is exceedingly rare, with this case illustrating an unusual diagnostic pathway of a well-understood condition, as well as representing an unfamiliar outcome following a common surgical intervention.

Canal to diaphysis ratio as a risk factor for hip fractures and hip fracture pattern.

INTRODUCTION: Osteoporosis and related fractures constitute a significant burden on modern healthcare. The standard method of diagnosing osteoporosis with a dual-energy X-ray absorptiometry (DXA) scan is limited by accessibility and expense. The thickness of the cortex of the proximal femur on plain radiographs has been suggested to be a method for indicating osteoporosis and as a risk factor of hip fractures in the elderly. METHODS: A retrospective study was undertaken to assess the usefulness of the canal-diaphysis ratio (CDR) as a risk factor for developing a hip fracture, excluding patients presenting under 50 years old, following high-energy trauma or pathological fractures. The CDR was measured in 84 neck of femur (NOF) fracture patients and 84 intertrochanteric hip fracture patients, and these were subsequently compared to the CDR of 84 patients without a hip fracture. Measurements were taken on two occasions by two members of the orthopaedic team, so as to assess the test's inter- and intraobserver reliability. RESULTS: In comparison to those without a fracture, there was a significant difference in the CDR of patients with a NOF fracture (P < 0.0001) and intertrochanteric fracture (P < 0.0001). Furthermore, the odds of having a CDR above 60.67 and 64.41 were significantly higher in the NOF (OR = 2.214, P = 0.0129) and intertrochanteric fracture (OR = 32.27, P < 0.0001) groups respectively, when compared to the non-fractured group. The analysis of the test's inter- and intraobserver reliability showed strong levels of reproducibility. DISCUSSION: We concluded that a raised CDR was associated with an increased incidence of NOF and intertrochanteric hip fracture. Measuring the CDR can thus be considered as a reproducible and inexpensive method of identifying elderly patients at risk of hip fractures.

Improving the Standard of Orthopaedic Operation Documentation Using Typed Proforma Operation Notes: A Completed Audit Loop.

INTRODUCTION: The Royal College of Surgeons (RCS) published Good Surgical Practice guidelines in 2008 and revised them in 2014. They outline the basic standard that all surgical operation notes should meet. OBJECTIVES: To retrospectively audit 57 typed orthopaedic operation notes from St. James's Hospital in Dublin (from August to November 2015) against the RCS Good Surgical Practice guidelines published in 2014. They were then compared with the department's previous audit of handwritten notes to complete the audit loop. MATERIALS AND METHODS: A total of 57 orthopaedic operation notes were audited by a single reviewer. They were prospectively collected between August and November 2015. All notes were typed on the standard St. James's Hospital operation note proforma. RESULTS: Of the surgeries, 89.5% were emergencies with 77.2% of them being performed by trainees. All of the operation notes were typed and signed by trainees. The procedure name, incision and closure details, tourniquet time (when relevant), and postoperative instructions were documented in 100% of the notes. In total, 80.7% had an operative diagnosis included while only 26.9% of the documentation had prosthesis serial numbers. All of the typed notes were deemed to be legible. CONCLUSION: The use of printed operation notes allows for improved legibility when compared to typed notes. Documentation standards remained very high in the same areas as the handwritten notes and a marked improvement was seen in areas that had been poorly documented.

A low-energy femoral shaft fracture from performing a yoga posture.

The femoral shaft is rarely the site of a low-energy fracture in a healthy individual. The vast majority of these fractures are due to major trauma such as motor vehicle accidents. Although low-energy femoral shaft fractures do occur, they are typically in patients with osteoporotic bone, or prosthesis related. In this case report, we present a man in his late 30s who was practising a specific yoga stance when he experienced a femoral shaft fracture.

Audit of Orthopaedic Surgical Documentation.

Introduction. The Royal College of Surgeons in England published guidelines in 2008 outlining the information that should be documented at each surgery. St. James's Hospital uses a standard operation sheet for all surgical procedures and these were examined to assess documentation standards. Objectives. To retrospectively audit the hand written orthopaedic operative notes according to established guidelines. Methods. A total of 63 operation notes over seven months were audited in terms of date and time of surgery, surgeon, procedure, elective or emergency indication, operative diagnosis, incision details, signature, closure details, tourniquet time, postop instructions, complications, prosthesis, and serial numbers. Results. A consultant performed 71.4% of procedures; however, 85.7% of the operative notes were written by the registrar. The date and time of surgery, name of surgeon, procedure name, and signature were documented in all cases. The operative diagnosis and postoperative instructions were frequently not documented in the designated location. Incision details were included in 81.7% and prosthesis details in only 30% while the tourniquet time was not documented in any. Conclusion. Completion and documentation of operative procedures were excellent in some areas; improvement is needed in documenting tourniquet time, prosthesis and incision details, and the location of operative diagnosis and postoperative instructions.

Assessment of the quality and content of information on anterior cruciate ligament reconstruction on the internet.

The Internet has become a major source of health information for the public. However, there are concerns regarding the quality, accuracy, and currency of medical information available online. We assessed the quality of information about anterior cruciate ligament (ACL) reconstruction on the first 60 websites returned by the 4 most popular search engines. Each site was categorized by type and assessed for quality and validity using the DISCERN score, the Journal of the American Medical Association (JAMA) benchmark criteria, and a novel ACL reconstruction-specific content score. The presence of the Health On the Net Code (HONcode), a purported quality assurance marker, was noted. The quality of information on ACL reconstruction available online is variable, with many websites omitting basic information regarding treatment options, risks, and prognosis. Commercial websites predominate. Academic and allied health professional websites attained the highest DISCERN and JAMA benchmark scores, whereas physician sites achieved the highest content scores. Sites that bore the HONcode seal obtained higher DISCERN and ACL reconstruction content scores than those without this certification. The HONcode seal is a reliable indicator of website quality, and we can confidently advise our patients to search for this marker.

Does anterior cruciate ligament reconstruction lead to degenerative disease?: Thirteen-year results after bone-patellar tendon-bone autograft.

BACKGROUND: Reporting of long-term outcome of anterior cruciate ligament (ACL) reconstruction with the patellar tendon (bone-patellar tendon-bone [BTB]) autograft is limited. There are concerns that degenerative joint disease is common in the long term, which may be associated with the procedure itself. HYPOTHESES: (1) ACL reconstruction with BTB provides good long-term outcome. (2) There are additional factors to surgical reconstruction that can be associated with the development of degenerative disease. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Of 161 patients, 114 were eligible. Patient-centered outcome was by Lysholm and subjective International Knee Documentation Committee (IKDC) score; objective outcome measures were clinical examination and IKDC radiological grade. RESULTS: Mean average follow-up was 13 years. The IKDC radiological grades in the worst compartment were A = 15%, B = 51%, C = 19%, and D = 14% (n = 83). There was a significant difference between the injured versus contralateral uninjured knee (n = 42, P = .003). In a subgroup with no meniscal or chondral injury the IKDC grades were A = 38%, B = 55%, C = 7%, and D = 0% (n = 29). The mean subjective scores were 89 ± 11 (Lysholm) and 83 ± 15 (IKDC) (n = 114). Poor IKDC subjective outcome was associated with chondral injury (P = .001), previous surgery (P = .022), return to sport (P = .013), and poor radiological grade in the ipsilateral medial compartment (P = .004). A poor IKDC radiological grade was associated with chondral injury (P = .002), meniscal injury (P = .010) and meniscectomy (P = .012), an IKDC subjective score of <85 (P = .01), and poor radiological grade in the contralateral medial compartment (P = .041). CONCLUSION: At 13 years, BTB ACL reconstruction provides a good outcome. Chondral and meniscal damage at surgery were associated with a poor radiological outcome, indicating that injuries sustained during ACL rupture may be the main predictors of degenerative bone disease.

Correction of severe hallux valgus using a basal chevron osteotomy and distal soft tissue release.

BACKGROUND: There are many procedures described for the correction of severe hallux valgus. This is the first to examine the role of a basal osteotomy with distal soft tissue release. METHODS: 26 patients with severe hallux valgus underwent a basal chevron osteotomy with distal soft tissue release. All were reviewed at an average of 38 months. RESULTS: The mean AOFAS score improved from 24 to 82 points (p<0.001). The IMA improved from an average of 23.90 to 130 (p<0.01). The HVA improved from an average of 490 to 170 (p<0.005). The correlation coefficient between the AOFAS score and various radiological angles was low (0.47). CONCLUSIONS: Good clinical outcomes in cases of severe hallux valgus can be achieved without full restoration of normal radiological values. Furthermore, a basal chevron osteotomy with a distal soft tissue release offers a high satisfaction rating with regards to both clinical and functional outcomes in the short to medium-term. LEVEL OF EVIDENCE: Level IV - Case series.