Mapping Staphylococcus aureus at Early and Late Stages of Infection in a Clinically Representative Hip Prosthetic Joint Infection Rat Model.

Prosthetic joint infection (PJI) continues to be a devastating complication following total joint replacement surgeries where Staphylococcus aureus is the main offending organism. To improve our understanding of the disease pathogenesis, a histological analysis of infected peri-implant tissue in a hip PJI rat model was utilized to assess S. aureus spread and tissue reaction at early and late stages of infection. Sprague-Dawley rats were used and received a left cemented hip hemiarthroplasty using a 3D-printed titanium femoral stem. The rats received an intra-articular injection of S. aureus Xen36. These infected rats were sacrificed either at 3 days post-infection (early-stage infection) or at 13-days post-infection (late-stage infection). The femoral and acetabular tissues of all animals were harvested at euthanasia. Histological analysis for the harvested tissue was performed using immunohistochemistry, hematoxylin and eosin, as well as Masson's trichrome stains. Histological examination revealed significant quantitative and qualitative differences in peri-implant tissue response to infection at early and late stages. This hip PJI rat model identified clear histologic differences between early and late stages of S. aureus infection and how quickly bacterial infiltration could occur. These findings can provide insight into why certain surgical strategies like debridement and antibiotics may be associated with high failure rates.

National Institute of Health and Care Excellence Guidelines for Displaced Intracapsular Hip Fractures: Examining Satisfaction With the Guidelines and Effects on Outcomes.

BACKGROUND: The objectives of the study were to: (1) evaluate satisfaction with the new 2023 National Institute of Health and Care Excellence (NICE) criteria for selecting total hip arthroplasty (THA) over hemiarthroplasty and surgical recommendations for treatment of displaced intracapsular hip fractures; (2) describe why THA is performed when NICE criteria are not met; and (3) determine whether satisfaction with these guidelines is associated with improved outcomes. METHODS: A retrospective chart review of patients who had a displaced intracapsular hip fracture treated with THA at a single tertiary academic center between 2010 and 2022 was performed. Preoperative patient characteristics were reviewed to determine if the indication for THA met NICE criteria. Operative details, perioperative complications, reoperation, and revision arthroplasty within 12 months of surgery were recorded. RESULTS: Data from 196 patients (63% women; age 67 ± 10 years) were used. There were 161 THAs (82.1%) that satisfied NICE criteria. The 2 most common reasons for performing a THA when NICE criteria were not met (n = 35) included preoperative radiographic osteoarthritis (Tönnis grade ≥ 2; 48.6%) and decreased patient age (< 65 years; 31.5%). Satisfaction with the NICE criteria was associated with fewer perioperative complications (0.6 versus 37.1%; P < .001), reoperations (0.6 versus 31.4%; P < .001), and revisions (0.6 versus 28.6%; P < .001). The most common reason for revision was periprosthetic fracture, possibly secondary to the use of uncemented femoral stems (171 of 196, 87.2%). CONCLUSIONS: Satisfaction with the new NICE criteria is associated with improved perioperative outcomes. Further studies are necessary to determine if preexisting hip osteoarthritis and younger age merit consideration in patient selection.

Lower Rates of Reoperation Following Partial or Complete Revision Arthroplasty Compared to Debridement, Antibiotics, and Implant Retention for Early Postoperative and Acute Hematogenous Periprosthetic Hip Infection.

BACKGROUND: This study aimed to: 1) compare treatment outcomes between debridement, antibiotics, and implant retention (DAIR) and partial or complete revision arthroplasty (RA) for early postoperative and acute hematogenous total hip arthroplasty periprosthetic joint infection (PJI) and 2) identify factors associated with treatment outcome. METHODS: The study consisted of a retrospective cohort of patients who underwent surgery for PJI between 2004 and 2021. There were 76 patients (74.5%) who underwent DAIR and 26 patients (25.5%) who underwent RA. Treatment success was defined as treatment eradication at a minimum of a 2-year follow up. Bivariate regression analysis was used to assess the effect of different factors on treatment outcomes. Kaplan-Meier survivorship was performed to compare survivorship between cohorts. RESULTS: At a mean follow-up of 8.2 years (range, 2.2 to 16.4), significantly more DAIR failed treatment (DAIR, 50 [65.8%]; 10 [38.5%]; P = .015). The 8-year Kaplan-Meier survivorship was 35.1% [95% confidence interval (CI), 24.3 to 45.9] for patients treated with DAIR and 61.5% [95% CI, 42.9 to 80.1] for those treated with RA (log rank = 0.039). Bivariate regression analysis showed performing a RA was associated with a higher likelihood of treatment success (odds ratio 4.499, 95% CI 1.600 to 12.647, P = .004), whereas a higher body mass index was associated with treatment failure (odds ratio 0.934, 95% CI 0.878 to 0.994, P = .032). CONCLUSIONS: To reduce the rate of recalcitrant infection following early postoperative or acute hematogenous total hip arthroplasty PJI, RA may be of benefit over DAIR. This is especially relevant in the early postoperative period, when components can be readily exchanged.

Tibiotalar nailing using an antegrade intramedullary tibial nail: a salvage procedure for unstable distal tibia and ankle fractures in the frail elderly patient.

AIM: This article describes the technique of tibiotalar nailing performed using an antegrade tibial nail for salvage of distal tibia and ankle fractures in elderly patients. MATERIALS AND METHODS: We report indications, surgical technique, and the clinical outcomes and complication rate in our series to date. A retrospective review was performed at our level 1 major trauma centre. Patient demographics, comorbidities, and 12-month post-operative course were collected. Fractures were classified using the OTA/AO and modified Gustilo-Anderson classification. Fifteen patients underwent the procedure. We present data with a minimum 12-month follow-up. The median age of the patients in this cohort was 83 years (range, 51-102). Five patients were diabetic. Six patients (6/15; 40%) presented with an open fracture. RESULTS: At final follow-up, fourteen patients reported painless walking and had returned to baseline activity. CONCLUSION: This technique may serve as a salvage procedure, with indications similar to those for tibio-talar-calcaneal arthrodesis. Indications would include non-constructible pilon fractures, comminuted intra-articular fractures in low-demand patients, or patients at high risk of wound complications. LEVEL OF CLINICAL EVIDENCE: 3.

Annual incidence and assessment of risk factors for early-onset deep surgical site infection following primary total knee arthroplasty in osteoarthritis.

Aims: This study aims to determine difference in annual rate of early-onset (≤ 90 days) deep surgical site infection (SSI) following primary total knee arthroplasty (TKA) for osteoarthritis, and to identify risk factors that may be associated with infection. Methods: This is a retrospective population-based cohort study using prospectively collected patient-level data between 1 January 2013 and 1 March 2020. The diagnosis of deep SSI was defined as per the Centers for Disease Control/National Healthcare Safety Network criteria. The Mann-Kendall Trend test was used to detect monotonic trends in annual rates of early-onset deep SSI over time. Multiple logistic regression was used to analyze the effect of different patient, surgical, and healthcare setting factors on the risk of developing a deep SSI within 90 days from surgery for patients with complete data. We also report 90-day mortality. Results: A total of 39,038 patients underwent primary TKA for osteoarthritis during the study period. Of these, 275 patients developed a deep SSI within 90 days of surgery, representing a cumulative incidence of 0.7%. The annual infection rate did not significantly decrease over the seven-year study period (p = 0.162). Overall, 13,885 (35.5%) cases were excluded from the risk analysis due to missing data. Risk factors associated with early-onset deep SSI included male sex, American Society of Anesthesiologists grade ≥ 3, blood transfusion, acute length of stay, and surgeon volume < 30 TKAs/year. Early-onset deep SSI was not associated with increased 90-day mortality. Conclusion: This study establishes a reliable baseline infection rate for early-onset deep SSI after TKA for osteoarthritis using robust Infection Prevention and Control surveillance data, and identifies several potentially modifiable risk factors.

Delayed mobilization following admission for hip fracture is associated with increased morbidity and length of hospital stay.

BACKGROUND: Current national guidelines on caring for hip fractures recommend early mobilization. However, this recommendation does not account for time spent immobilized waiting for surgery. We sought to determine timing of mobilization following hip fracture, beginning at hospital admission, and evaluate its association with medical complications and length of hospital stay (LOS). METHODS: We performed a retrospective review of prospectively collected data for 470 consecutive patients who underwent surgery for a hip fracture between September 2019 and August 2020 at an academic, tertiary-referral hospital. Outcomes of interest included time from hospital admission to mobilization, complication rate and LOS. We used a binary regression analysis to determine the effect of different surgical and patient factors on the risk of a postoperative medical complication. RESULTS: The mean time from admission to mobilization was 2.8 ± 2.3 days (range 3 h-14 d). There were 125 (26.6%) patients who experienced at least 1 complication. The odds of developing a complication began to increase steadily once a patient waited more than 3 days from admission to mobilization (odds ratio 2.15, 95% confidence interval 1.42-3.25). Multivariate regression analysis showed that prefracture frailty (ß = 0.276, p = 0.05), and timing from hospital admission to mobilization (ß = 0.156, p < 0.001) and from surgery to mobilization (ß = 1.195, p < 0.001) were associated with complications. The mean LOS was 12.2 ± 10.7 days (range 1-90 d). Prolonged wait to mobilization was associated with longer LOS (p = 0.01). CONCLUSION: Comprehensive guidelines on timing of mobilization following hip fracture should account for cumulative time spent immobilized.

A comparison of clinical and radiological outcomes between two different biodegradable local antibiotic carriers used in the single-stage surgical management of long bone osteomyelitis.

Aims: Dead-space management, following dead bone resection, is an important element of successful chronic osteomyelitis treatment. This study compared two different biodegradable antibiotic carriers used for dead-space management, and reviewed clinical and radiological outcomes. All cases underwent single-stage surgery and had a minimum one-year follow-up. Methods: A total of 179 patients received preformed calcium sulphate pellets containing 4% tobramycin (Group OT), and 180 patients had an injectable calcium sulphate/nanocrystalline hydroxyapatite ceramic containing gentamicin (Group CG). Outcome measures were infection recurrence, wound leakage, and subsequent fracture involving the treated segment. Bone-void filling was assessed radiologically at a minimum of six months post-surgery. Results: The median follow-up was 4.6 years (interquartile range (IQR) 3.2 to 5.4; range 1.3 to 10.5) in Group OT compared to 4.9 years (IQR 2.1 to 6.0; range 1.0 to 8.3) in Group CG. The groups had similar defect sizes following excision (both mean 10.9 cm3 (1 to 30)). Infection recurrence was higher in Group OT (20/179 (11.2%) vs 8/180 (4.4%), p = 0.019) than Group CG, as was early wound leakage (33/179 (18.4%) vs 18/180 (10.0%), p = 0.024) and subsequent fracture (11/179 (6.1%) vs 1.7% (3/180), p = 0.032). Group OT cases had an odds ratio 2.9-times higher of developing any one of these complications, compared to Group CG (95% confidence interval 1.74 to 4.81, p < 0.001). The mean bone-void healing in Group CG was better than in Group OT, in those with ≥ six-month radiological follow-up (73.9% vs 40.0%, p < 0.001). Conclusion: Local antibiotic carrier choice affects outcome in chronic osteomyelitis surgery. A biphasic injectable carrier with a slower dissolution time was associated with better radiological and clinical outcomes compared to a preformed calcium sulphate pellet carrier.

Management of complex regional pain syndrome in trauma and orthopaedic surgery-a systematic review.

INTRODUCTION: Complex regional pain syndrome (CRPS) is a neurological pain disorder that is challenging to diagnose and manage, resulting in increased morbidity and costs. It most commonly occurs following traumatic injury, such as a fracture, crush injury or surgery. Recent research has evaluated the efficacy of treatments which have contradicted previous hypotheses. This systematic review summarizes these findings to improve clinician's decision-making. SOURCES OF DATA: A comprehensive search of PubMed, MEDLINE and Embase databases from inception through January 2021 was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Two reviewers independently screened relevant articles discussing the management of CRPS in adult trauma patients. All prospective and retrospective studies, non-randomized comparison studies and case series were considered for inclusion. Data extraction was performed by populating a predefined data abstraction sheet. AREAS OF AGREEMENT: There is strong evidence to suggest the efficacy of prompt physiotherapy, lidocaine, ketamine, bisphosphonates, sympathectomy and brachial plexus blocks in the management of CRPS. AREAS OF CONTROVERSY: The latest evidence suggests that vitamin C has no significant role to play in the treatment or prevention of CRPS. GROWING POINTS: A multidisciplinary team approach and early diagnosis are imperative for successful treatment of CRPS. The Budapest criteria and the British Orthopaedic Association Standards for Trauma and Orthopaedics (BOAST) guidelines should be used when diagnosing CRPS. There is currently no clear evidence of superiority in any treatment. AREAS TIMELY FOR DEVELOPING RESEARCH: There are few high-quality studies that inform the best treatment modalities for CRPS. Though emerging treatments show promise, further research is needed.

Is Outcome of Total Hip Arthroplasty for Hip Fracture Inferior to That of Arthritis in a Contemporary Arthroplasty Practice?

BACKGROUND: Outcome of total hip arthroplasty (THA) for femoral neck fractures (FNF) has been associated with higher complication rates. However, THA for FNF is not always performed by arthroplasty surgeons. This study aimed to compare THA outcomes for FNF to osteoarthritis (OA). In doing so, we described contemporary THA failure modes for FNF performed by arthroplasty surgeons. METHODS: This was a retrospective, multisurgeon study from an academic center. Of FNFs treated between 2010 and 2020, 177 received THA by an arthroplasty surgeon [mean age 67 years (range, 42 to 97), sex: 64.4% women]. These were matched (1:2) for age and sex with 354 THAs performed for hip OA, by the same surgeons. No dual-mobilities were used. Outcomes included radiologic measurements (inclination/anteversion and leg length), mortality, complications, reoperation rates and patient-reported outcomes including Oxford Hip Score. RESULTS: Postoperative mean leg-length difference was 0 mm (range, -10 to -10 mm), with a mean cup inclination and anteversion of 41 and 26°, respectively. There was no difference in radiological measurements between FNF and OA patients (P = .3). At a 5-year follow-up, mortality rate was significantly higher in the FNF-THA group compared to the OA-THA group (15.3 versus 1.1%; P < .001). There was no difference in complications (7.3 versus 4.2%; P = .098) or reoperation rates (5.1 versus 2.9%; P = .142) between the groups. Dislocation rate was 1.7%. Oxford Hip Score at the final follow-up was similar [43.7 points (range, 10 to 48) versus 43.6 points (range, 10 to 48); P = .030]. CONCLUSION: THA for the treatment of FNF is a reliable option and is associated with satisfactory outcomes. Instability was not a common reason of failure, despite not using dual-mobility articulations in this at-risk population. This is likely due to THAs being performed by the arthroplasty staff. When patients live beyond 2 years, similar clinical and radiographic outcomes with low rates of revision can be expected compared to elective THA for OA. LEVEL OF EVIDENCE: III, case-control study.

Periprosthetic joint infection following hip hemiarthroplasty : factors associated with infection and treatment outcome.

AIMS: The aims of this study were to determine the incidence and factors for developing periprosthetic joint infection (PJI) following hemiarthroplasty (HA) for hip fracture, and to evaluate treatment outcome and identify factors associated with treatment outcome. METHODS: A retrospective review was performed of consecutive patients treated for HA PJI at a tertiary referral centre with a mean 4.5 years' follow-up (1.6 weeks to 12.9 years). Surgeries performed included debridement, antibiotics, and implant retention (DAIR) and single-stage revision. The effect of different factors on developing infection and treatment outcome was determined. RESULTS: A total of 1,984 HAs were performed during the study period, and 44 sustained a PJI (2.2%). Multiple logistic regression analysis revealed that a higher CCI score (odds ratio (OR) 1.56 (95% confidence interval (CI) 1.117 to 2.187); p = 0.003), peripheral vascular disease (OR 11.34 (95% CI 1.897 to 67.810); p = 0.008), cerebrovascular disease (OR 65.32 (95% CI 22.783 to 187.278); p < 0.001), diabetes (OR 4.82 (95% CI 1.903 to 12.218); p < 0.001), moderate-to-severe renal disease (OR 5.84 (95% CI 1.116 to 30.589); p = 0.037), cancer without metastasis (OR 6.42 (95% CI 1.643 to 25.006); p = 0.007), and metastatic solid tumour (OR 15.64 (95% CI 1.499 to 163.087); p = 0.022) were associated with increasing PJI risk. Upon final follow-up, 17 patients (38.6%) failed initial treatment and required further surgery for HA PJI. One-year mortality was 22.7%. Factors associated with treatment outcome included lower preoperative Hgb level (97.9 g/l (SD 11.4) vs 107.0 g/l (SD 16.1); p = 0.009), elevated CRP level (99.1 mg/l (SD 63.4) vs 56.6 mg/l (SD 47.1); p = 0.030), and type of surgery. There was lower chance of success with DAIR (42.3%) compared to revision HA (66.7%) or revision with conversion to total hip arthroplasty (100%). Early-onset PJI (≤ six weeks) was associated with a higher likelihood of treatment failure (OR 3.5 (95% CI 1.2 to 10.6); p = 0.007) along with patients treated by a non-arthroplasty surgeon (OR 2.5 (95% CI 1.2 to 5.3); p = 0.014). CONCLUSION: HA PJI initially treated with DAIR is associated with poor chances of success and its value is limited. We strongly recommend consideration of a single-stage revision arthroplasty with cemented components.Cite this article: Bone Jt Open 2022;3(12):924-932.

Comparing 1-year and 10-year whole blood metal ion results following Birmingham hip resurfacing for osteoarthritis.

BACKGROUND: Patients with metal-on-metal hip arthroplasty may develop adverse reactions to metal debris that can lead to clinically concerning symptoms, often needing revision surgery. As such, many regulatory authorities advocate for routine blood metal ion measurement. This study compares whole blood metal ion levels obtained 1 year following Birmingham Hip Resurfacing (BHR) to levels obtained at a minimum 10-year follow-up. METHODS: A retrospective chart review was conducted to identify all patients who underwent a BHR for osteoarthritis with a minimum 10-year follow-up. Whole blood metal ion levels were obtained at final follow-up in June 2019. These results were compared with patients' metal ion levels at 1 year. RESULTS: Of the 211 patients who received a BHR, 71 patients (54 males and 17 females) had long-term metal ion levels assessed (mean follow-up 12.7 ± 1.4 yr). The mean cobalt and chromium levels for patients with unilateral BHRs (43 males and 13 females) were 3.12 ± 6.31 µg/L and 2.62 ± 2.69 µg/L, respectively; for patients with bilateral BHRs (11 males and 4 females) cobalt and chromium levels were 2.78 ± 1.02 µg/L and 1.83 ± 0.65 µg/L, respectively. Thirty-five patients (27 male and 8 female) had metal ion levels tested at 1 year postoperatively. The mean changes in cobalt and chromium levels were 2.29 µg/L (p = 0.0919) and 0.57 µg/L (p = 0.1612), respectively. CONCLUSION: Our results suggest that regular metal ion testing as per current regulatory agency guidelines may be impractical for asymptomatic patients. Metal ion levels may in fact have little utility in determining the risk of failure and should be paired with radiographic and clinical findings to determine the need for revision.

Perioperative outcomes associated with general and spinal anesthesia after total joint arthroplasty for osteoarthritis: a large, Canadian, retrospective cohort study.

BACKGROUND: Compared with general anesthesia, spinal anesthesia has many benefits for patients undergoing total hip (THA) or total knee (TKA) arthroplasty, but few studies have explored rates of morbidity and mortality. We aimed to compare perioperative outcomes by anesthetic type for patients undergoing THA or TKA for osteoarthritis. METHODS: We identified patients who underwent primary THA or TKA from the affiliated institute's database. We calculated inpatient, 30-day, 60-day and 90-day mortality rates, as well as 90-day perioperative complications, readmissions and length of stay (LOS). We compared outcomes between groups using logistic regression and propensity-adjusted multivariate analysis. RESULTS: We included 6100 (52.2%) patients undergoing THA and 5580 (47.8%) undergoing TKA. We found no differences by anesthetic type in mortality rates up to 90 days after surgery. Patients under spinal anesthesia were less likely to need a blood transfusion (THA odds ratio [OR] 0.75, 95% confidence interval [CI] 0.60 to 0.92; TKA OR 0.52, 95% CI 0.40 to 0.67) and were more likely to be discharged home among those who underwent TKA (OR 1.61, 95% CI 1.30 to 2.00). Patients who received spinal anesthesia for THA had a longer LOS (0.28 d, 95% CI 0.17 to 0.39), and patients who received spinal anesthesia for TKA had a shorter LOS than those who received general anesthesia (-0.34 d, 95% CI -0.51 to -0.18). Anesthetic type was not associated with any difference in adverse events. CONCLUSION: These findings may inform decisions on anesthetic type for total joint arthroplasty, especially for rapid discharge protocols. Further research is needed to understand postoperative pain and functional outcomes between anesthetic types.

Birmingham Hip Resurfacing for osteoarthritis - a Canadian retrospective cohort study with a minimum 10-year follow-up.

BACKGROUND: Young men with osteoarthritis of the hip are a growing segment of the population requiring arthroplasty, and there is compelling evidence that the Birmingham Hip Resurfacing (BHR) system provides good functional outcomes and durability in young, active men. We reviewed the survivorship and clinical outcomes of patients who underwent BHR with a minimum follow-up of 10 years. METHODS: We analyzed survivorship using the Kaplan-Meier method. Functional scoring was performed using the Harris Hip Score (HHS), the University of California, Los Angeles (UCLA) Activity Score, and a visual analogue scale (VAS). RESULTS: In total, 211 patients (243 hips) were included in the study. Of these, 107 patients (127 hips) were available for long-term clinical follow-up, with a mean duration of 12.4 ± 1.4 years. The proportion of male participants with BHRs surviving past 13 years was 93.8% (95% confidence interval [CI] 87.9%-100%) compared with 87% (95% CI 77.8%-97.3%) of female patients. Eleven patients (11 hips) underwent BHR revision. Upon final follow-up, the median HHS was 93.9 in males and 93.6 in females (p = 0.27); median UCLA Activity Score was 8.2 in males and 7.2 in females (p < 0.001), and the median VAS score was 81.9 in males and 81.3 in females (p = 0.35). The median acetabular component inclination was 45.5° ± 6.0° (range 34.6°-57.2°) in males and 44.6° ± 5.9° (range 29°-58.9°) in females. The most common femoral head size was 50 mm with a 56 mm or 58 mm cup (36.3%). CONCLUSION: This study confirms that BHR provides good to excellent functional outcomes, lasting functional improvements, and acceptable durability beyond 10 years in men. Survivorship following BHR is inferior in women; however, HHS and VAS scores were similar in women and men.

Effects of Perioperative Selective Serotonin Reuptake Inhibitor Use in Primary Total Hip and Knee Arthroplasty.

BACKGROUND: The aim of this study is to compare functional outcomes and perioperative complications between patients on a selective serotonin reuptake inhibitor (SSRI) and those who are not on an SSRI preoperatively at the time of total joint arthroplasty. METHODS: A retrospective study was performed on 28,386 patients who received a primary total hip (THA) or knee (TKA) arthroplasty. Patients were compared based on SSRI utilization. We measured patient-reported function and health-related quality of life using the Western Ontario and McMaster Universities Arthritis Index (WOMAC) and the EuroQol-5 Dimensions (EQ-5D-5L) instruments. Chi-squared test was used to compare categorical variables and t-test was used to compare the continuous variables of 2 study groups. RESULTS: Patients on SSRIs have lower preoperative baseline WOMAC and EQ-5D-5L scores than those not using SSRI (P < .001). Patient-reported outcomes improved significantly following surgery, but functional outcome scores remained inferior in patients using SSRI. After adjusting for baseline variables, SSRI use in TKA predicted lower EQ-5D-5L scores than non-SSRI users (P = .036) while the WOMAC scores were not different (P = .118). For the THA cohort, SSRI use predicted lower EQ-5D-5L (P = .001) and WOMAC scores than non-SSRI users (P = .008). SSRI use was associated with increased transfusion rate, length of stay, readmission rate, and medical events. About 11.3% of TKA and 13.3% of THA patients stopped using SSRI at 12 months after arthroplasty. CONCLUSION: Patients using an SSRI show improvement comparable to patients not on an SSRI, but their 12-month functional scores continue to be inferior. SSRI utilization was associated with increased adverse events including needing a blood transfusion.

Assessment of risk factors for early-onset deep surgical site infection following primary total hip arthroplasty for osteoarthritis.

The aim of this study was to determine the incidence, annual trend, and perioperative outcomes and identify risk factors of early-onset ( ≤ 90  d) deep surgical site infection (SSI) following primary total hip arthroplasty (THA) for osteoarthritis. We performed a retrospective study using prospectively collected patient-level data from January 2013 to March 2020. The diagnosis of deep SSI was based on the published Centre for Disease Control/National Healthcare Safety Network (CDC/NHSN) definition. The Mann-Kendall trend test was used to detect monotonic trends. Secondary outcomes were 90 d mortality and 90 d readmission. A total of 22 685 patients underwent primary THA for osteoarthritis. A total of 46 patients had a confirmed deep SSI within 90 d of surgery representing a cumulative incidence of 0.2 %. The annual infection rate decreased over the 7-year study period ( p = 0.026 ). Risk analysis was performed on 15 466 patients. Risk factors associated with early-onset deep SSI included a BMI  >  30 kg m - 2 (odds ratio (OR) 3.42 [95 % CI 1.75-7.20]; p < 0.001 ), chronic renal disease (OR, 3.52 [95 % CI 1.17-8.59]; p = 0.011 ), and cardiac illness (OR, 2.47 [1.30-4.69]; p = 0.005 ), as classified by the Canadian Institute for Health Information. Early-onset deep SSI was not associated with 90 d mortality ( p = 0.167 ) but was associated with an increased chance of 90 d readmission ( p < 0.001 ). This study establishes a reliable baseline infection rate for early-onset deep SSI after THA for osteoarthritis through the use of a robust methodological process. Several risk factors for early-onset deep SSI are potentially modifiable, and therefore targeted preoperative interventions of patients with these risk factors is encouraged.

Cost-effectiveness of dual-mobility components in patients with displaced femoral neck fractures.

AIMS: Total hip arthroplasty (THA) with dual-mobility components (DM-THA) has been shown to decrease the risk of dislocation in the setting of a displaced neck of femur fracture compared to conventional single-bearing THA (SB-THA). This study assesses if the clinical benefit of a reduced dislocation rate can justify the incremental cost increase of DM-THA compared to SB-THA. METHODS: Costs and benefits were established for patients aged 75 to 79 years over a five-year time period in the base case from the Canadian Health Payer's perspective. One-way and probabilistic sensitivity analysis assessed the robustness of the base case model conclusions. RESULTS: DM-THA was found to be cost-effective, with an estimated incremental cost-effectiveness ratio (ICER) of CAD $46,556 (£27,074) per quality-adjusted life year (QALY). Sensitivity analysis revealed DM-THA was not cost-effective across all age groups in the first two years. DM-THA becomes cost-effective for those aged under 80 years at time periods from five to 15 years, but was not cost-effective for those aged 80 years and over at any timepoint. To be cost-effective at ten years in the base case, DM-THA must reduce the risk of dislocation compared to SB-THA by at least 62%. Probabilistic sensitivity analysis showed DM-THA was 58% likely to be cost-effective in the base case. CONCLUSION: Treating patients with a displaced femoral neck fracture using DM-THA components may be cost-effective compared to SB-THA in patients aged under 80 years. However, future research will help determine if the modelled rates of adverse events hold true. Surgeons should continue to use clinical judgement and consider individual patients' physiological age and risk factors for dislocation. Cite this article: Bone Joint J 2021;103-B(12):1783-1790.

Early Complications in Vertical Expandable Prosthetic Titanium Rib and Magnetically Controlled Growing Rods to Manage Early Onset Scoliosis.

OBJECTIVES: The aim of this study is to examine whether surgical treatment of early onset scoliosis (EOS) with magnetically controlled growing rods (MCGRs) or a vertical expandable prosthetic titanium rib (VEPTR) resulted in fewer short-term (24 months) complications and reoperations. BACKGROUND: EOS is a challenging problem for spine surgeons that has been managed with different growth-friendly instrumentation systems. Although rib-based devices encourage spinal growth via regular lengthening, the high rate of complications and reoperations leads us to use spine-based devices such as MCGRs to mitigate this concern. METHODS: A total of 35 EOS patients were included in the study. Twenty patients were included in the VEPTR group, and 15 patients were included in the MCGR group. Demographic data and 2 years of postoperative complications and reoperations were reviewed retrospectively. As secondary outcomes, radiographic outcomes were reported preoperatively and 1 year after surgery. Indications for this technique and complications were collected from the charts. RESULTS: Demographic data showed no significant differences between the 2 groups. Significant differences were found in the complications rate at 2 years, with 65% complications in the VEPTR group and 13.3% complications in the MCGR group (P < .001). The reoperation rate at 2 years was also significantly higher in the VEPTR group, with 50% versus 13.3% in the MCGR group (P = .0009). As secondary outcomes, radiological parameters such as main curve Cobb angle correction (P = .001) and apical vertebral translation (P = .002) were significantly higher in the MCGR group. Significant differences were also found in sagittal profile parameters; T1-T12 and T1-S1 were significantly higher in the MCGR group (P < .001). CONCLUSIONS: According to our results, VEPTR has significantly higher complication and reoperation rates at 2 years postsurgery compared with MCGR. LEVEL OF EVIDENCE: 4.

Postoperative fever in the time of COVID-19.

Summary: Postoperative fever is common following orthopedic trauma surgery. As the prevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection increases in the community, migration into the acute care hospital setting intensifies, creating confusion when fever develops postoperatively. The transmission dynamics of SARS-CoV-2 make it difficult to adequately gauge and pinpoint risk groups with questionnaires at the time of hospital admission. This is particularly problematic when asymptomatic or presymptomatic patients infected with SARS-CoV-2 require urgent surgery and cannot be screened effectively. One approach is to treat every patient as though they were SARS-CoV-2-positive in preparation for surgery, but doing so could exacerbate shortages of personal protective equipment and staffing limitations. Uncertainty regarding the etiology of postoperative fever could be significantly reduced by universal SARS-CoV-2 testing of all surgical patients at the time of hospital admission in addition to routine screening, but testing capacity and a rapid turnaround time would be required.

Staged instrumentation with magnetically controlled growing rods in early-onset scoliosis: indications and preliminary outcomes.

BACKGROUND: Severe scoliosis, kyphosis, stiffer curves, short trunk height, and poor bone density are known risk factors for instrumentation failure with traditional growing rods or magnetically controlled growing rods (MCGR). To minimize the risk of instrumentation failure in managing complex early-onset scoliosis (EOS) with MCGR, we propose a strategy for staged MCGR insertion. METHODS: We performed a single-center retrospective review of all consecutive MCGR cases with 24 months' minimum follow-up. Inclusion criteria included diagnosis of EOS of any etiology with severe and stiff curves in the coronal or sagittal planes, poor bone density, short trunk height (T1-T12 smaller than 150 mm) or previous instrumentation failure managed with staged MCGR. During the first stage, anchor points and halo-gravity were applied, followed by halo-gravity traction. At a second stage, halo-gravity was removed and MCGR were inserted. Outcome measures included pre- and postoperative radiographic measurements and complications. RESULTS: Seventeen patients with a median age of 7 (range 6-9) years were managed in two stages. Indications for two-stage surgery were short trunk height (T1-T12 height less than 150 mm) in six patients, five poor bone quality, three dislodgement of proximal anchor points in previous instrumentation, and three rigid curves. The rate of unplanned revision surgeries was 11.8%. No infections or traction-related complications were found. CONCLUSIONS: According to our results, the staged MCGR insertion strategy combined with halo-gravity traction to manage complex EOS yielded a relatively low instrumentation failure rate as compared with the rates previously reported in the current literature. To our knowledge, this is the first study reporting the staged strategy for instrumentation with MCGR. LEVEL OF EVIDENCE: IV.