The characteristics and predictors of mortality in periprosthetic fractures around the knee.

Aims: Periprosthetic fractures (PPFs) around the knee are challenging injuries. This study aims to describe the characteristics of knee PPFs and the impact of patient demographics, fracture types, and management modalities on in-hospital mortality. Methods: Using a multicentre study design, independent of registry data, we included adult patients sustaining a PPF around a knee arthroplasty between 1 January 2010 and 31 December 2019. Univariate, then multivariable, logistic regression analyses were performed to study the impact of patient, fracture, and treatment on mortality. Results: Out of a total of 1,667 patients in the PPF study database, 420 patients were included. The in-hospital mortality rate was 6.4%. Multivariable analyses suggested that American Society of Anesthesiologists (ASA) grade, history of peripheral vascular disease (PVD), history of rheumatic disease, fracture around a loose implant, and cerebrovascular accident (CVA) during hospital stay were each independently associated with mortality. Each point increase in ASA grade independently correlated with a four-fold greater mortality risk (odds ratio (OR) 4.1 (95% confidence interval (CI) 1.19 to 14.06); p = 0.026). Patients with PVD have a nine-fold increase in mortality risk (OR 9.1 (95% CI 1.25 to 66.47); p = 0.030) and patients with rheumatic disease have a 6.8-fold increase in mortality risk (OR 6.8 (95% CI 1.32 to 34.68); p = 0.022). Patients with a fracture around a loose implant (Unified Classification System (UCS) B2) have a 20-fold increase in mortality, compared to UCS A1 (OR 20.9 (95% CI 1.61 to 271.38); p = 0.020). Mode of management was not a significant predictor of mortality. Patients managed with revision arthroplasty had a significantly longer length of stay (median 16 days; p = 0.029) and higher rates of return to theatre, compared to patients treated nonoperatively or with fixation. Conclusion: The mortality rate in PPFs around the knee is similar to that for native distal femur and neck of femur fragility fractures. Patients with certain modifiable risk factors should be optimized. A national PPF database and standardized management guidelines are currently required to understand these complex injuries and to improve patient outcomes.

Predictors of mortality in periprosthetic fractures of the hip: Results from the national PPF study.

INTRODUCTION: Periprosthetic fractures (PPFs) around the hip joint are increasing in prevalence. In this collaborative study, we aimed to investigate the impact of patient demographics, fracture characteristics, and modes of management on in-hospital mortality of PPFs involving the hip. METHODS: Using a multi-centre cohort study design, we retrospectively identified adults presenting with a PPF around the hip over a 10-year period. Univariate and multivariable logistic regression analyses were performed to study the independent correlation between patient, fracture, and treatment factors on mortality. RESULTS: A total of 1,109 patients were included. The in-hospital mortality rate was 5.3%. Multivariable analyses suggested that age, male sex, abbreviated mental test score (AMTS), pneumonia, renal failure, history of peripheral vascular disease (PVD) and deep surgical site infection were each independently associated with mortality. Each yearly increase in age independently correlates with a 7% increase in mortality (OR 1.07, p=0.019). The odds of mortality was 2.99 times higher for patients diagnosed with pneumonia during their hospital stay [OR 2.99 (95% CI 1.07-8.37) p=0.037], and 7.25 times higher for patients that developed renal failure during their stay [OR 7.25 (95% CI 1.85-28.47) p=0.005]. Patients with history of PVD have a six-fold greater mortality risk (OR 6.06, p=0.003). Mode of treatment was not a significant predictor of mortality. CONCLUSION: The in-hospital mortality rate of PPFs around the hip exceeds 5%. The fracture subtype and mode of management are not independent predictors of mortality, while patient factors such as age, AMTS, history of PVD, pneumonia, and renal failure can independently predict mortality. Peri-operative optimisation of modifiable risk factors such as lung and kidney function in patients with PPFs around the hip during their hospital stay is of utmost importance.

Management of Open Ankle Fractures in Elderly Patients With a Fibula Nail is a Safe and Reliable Technique.

BACKGROUND: Ankle fractures are becoming more common in the elderly and their management is frequently challenging. There is increasing evidence of good outcomes following fibula nail fixation in the management of ankle fractures. The use of a fibula nail in open fractures comes with potential advantages such as minimal soft tissue dissection, early rehabilitation, and decreased wound complications. We aimed to assess their use in the management of open ankle fractures in the elderly. METHODS: A review of patients aged 60 years or older with an open ankle fracture treated with a fibular nail at a major trauma center was conducted. All patients were managed with joint Orthopaedic and Plastic Surgical input to determine their optimal management. Functional outcome scores, postoperative complications, and re-operation rates were determined. RESULTS: Fifteen patients were identified with a mean age of 76 years. Patient-reported outcomes (Olerud and Molander Score) were calculated in 73% of patients. Our results demonstrated excellent outcome scores (>91) in 1 patient, good outcome scores (61-90) in 7 patients, and fair outcome scores (31-60) in 3 patients. There were no postoperative complications or re-operations within our study group. CONCLUSION: This article is the largest series presenting the outcomes of fibula nails in the management of open ankle fractures in elderly patients. We conclude that it can be used as a treatment option to safely manage open ankle fractures in the elderly. It provides a stable fixation, early weight-bearing, low risk of postoperative complications while maintaining good patient-reported functional outcomes. LEVEL OF EVIDENCE: Level 4.

Traumatic hip dislocation in the paediatric population: A case series from a specialist centre.

INTRODUCTION: Traumatic hip dislocation is a rare injury in the paediatric population. It can occur after high energy trauma, but also after lower energy injuries especially in younger children. Posterior dislocation is the most common pattern of hip dislocation. In most cases, closed reduction is successful, but occasionally open reduction is required to achieve concentric reduction. The aim of our study was to present the 10-year experience from a Level-1 Trauma Paediatric Hospital and to comment on how our experience correlates with the current literature. PATIENTS AND METHODS: This is a retrospective case series of all paediatric patients (< 16 years old) with a traumatic hip dislocation presented and/or treated at our institution, between the 1st of January 2010 and 31st August 2020. RESULTS: Thirteen cases of traumatic hip dislocation were identified. There were 7 females. The mean age was 9.8 years. Typically, younger patients were involved in lower energy injuries. The direction of hip dislocation was posterior in ten cases. Associated injuries were seen in eight patients. All cases underwent closed reduction, which was successful in nine cases. Mean time to reduction was 6.8 hours. Post reduction imaging with CT and/or MRI was performed in all cases. There was residual subluxation in three cases, requiring open reduction. In one case with unrecognised undisplaced physeal injury, closed reduction resulted in a Delbet type 1 hip fracture. Two cases developed avascular necrosis (AVN). CONCLUSIONS: Traumatic paediatric hip dislocation is a rare injury. A target of 6 hours for reduction should be employed as this will reduce the risk of AVN in those who have not permanently damaged the vessels at the time of injury. We advocate all attempts for closed reduction to be performed in an operating theatre with the use of an image intensifier to help identifying associated injuries and confirm concentric reduction. If closed reduction fails, open reduction is required. Post-reduction MRI is an important adjunct to recognise associated soft tissue injuries. Follow up of patients should continue for 2 years as a minimum to help detect AVN.

Orthoplastic Management of Open Midfoot Injuries: Is Functional Limb Salvage Possible?

High energy open midfoot injuries are uncommon but devastating injuries. A combination of complex fracture dislocations and soft tissue injury patterns render reconstruction challenging. The aim of this study was to assess the surgical and patient reported outcomes following orthoplastic management of open midfoot injuries in a Major Trauma Center. A retrospective review of all open midfoot fractures admitted to our unit between January 2015 and December 2016 was undertaken. Demographics, operative details, complications, additional surgeries, and patient reported outcomes in the form of EQ-5D and Enneking scores were collected. Fifteen patients were identified (13 male, mean age 39.2 years). One patient underwent amputation at initial debridement and 8 required additional debridement. Of these 8 patients, 3 had an amputation during their index admission. In the limb salvage group (11 patients), definitive soft tissue cover involved free flaps in 6 patients, split skin graft in 3 patients, and delayed primary closure in 2 patients. Definitive orthopedic treatment was internal fixation in 8 and external fixation in 3 patients. Two patients required a Masquelet procedure for bone loss. One patient had a toe amputation and 1 had a below knee amputation for deep infection. The median EQ-5D score was 66 (interquartile range 43), and the median Enneking score was 20.5 (interquartile range 9). Limb salvage following open midfoot fractures is technically possible in most cases, however this often involves multiple procedures and the outcomes are variable and difficult to predict. Patients should be carefully counseled, and amputation considered in all such cases.

A Rare Case Of Sigmoid Colon Perforation With Subsequent Psoas Abscess Collection With Extensive Involvement Of The Sartorius Muscle.

A middle-aged man was admitted with worsening hip pain, fevers and reduced mobility. These symptoms were preceded by a mechanical fall but despite regular analgesia, symptoms did not resolve. His prior medical history included ischaemic heart disease, hypertension and hypercholesterolaemia. A trauma and orthopaedic review revealed a painful left hip with reduced range of motion. In addition, some mild tenderness in the left iliac fossa was noted. Blood tests revealed markedly raised inflammatory markers. Plain radiographs and ultrasound were normal. MRI scan found a massive left iliopsoas collection secondary to perforated diverticular disease of the sigmoid colon. The patient was managed with intravenous antibiotics and the collection was drained percutaneously. Approximately 500 mL of pus was aspirated. The patient made an excellent recovery with interval imaging showing a reduction in the collection size.