Fracture risk assessment and evaluation of femoroplasty in metastatic proximal femurs. An in vivo CT-based finite element study.

The goal of this study was twofold. First, we aimed to evaluate the accuracy of a finite element (FE) model to predict bone fracture in cancer patients with proximal femoral bone metastases. Second, we evaluated whether femoroplasty could effectively reduce fracture risk. A total of 89 patients were included, with 101 proximal femurs affected with bone metastases. The accuracy of the model to predict fracture was evaluated by comparing the FE failure load, normalized for body weight, against the actual occurrence of fracture during a 6-month follow-up. Using a critical threshold, the model could identify whether femurs underwent fracture with a sensitivity of 92% and a specificity of 66%. A virtual treatment with femoroplasty was simulated in a subset of 34 out of the 101 femurs; only femurs with one or more well-defined lytic lesions were considered eligible for femoroplasty. We modeled their lesions, as well as the surrounding 4 mm of trabecular bone, to be augmented with bone cement. The simulation of femoroplasty increased the median failure load of the FE model by 57% for lesions located in the head/neck of the femur. At this lesion location, all high risk femurs that had fractured during follow-up effectively moved from a failure load below the critical threshold to a value above. For lesions located in the trochanteric region, no definite improvement in failure load was found. Although additional validation studies are required, our results suggest that femoroplasty can effectively reduce fracture risk for several osteolytic lesions in the femoral head/neck.

Is open acute Achilles tendon rupture repair still justified? A single center experience and critical appraisal of the literature.

INTRODUCTION: Acute Achilles tendon ruptures are injuries with multiple treatment strategies with possibly far reaching consequences. Open repair is associated with a high complication rate, whereas percutaneous techniques are associated with higher re-rupture rates. The goal of this study was to evaluate the clinical outcome and economic burden of open surgical repair and define a medically and economically sound treatment protocol for acute Achilles tendon ruptures. METHODS: Between June 2012 and December 2016 one hundred and five patients with an acute Achilles tendon rupture, treated in an open surgical manner, were studied retrospectively. All demographic, clinical and hospital-related costs were retrieved from the electronic patient database. ATRS questionnaires were sent to assess the functional outcome. A response rate of 70.5% was achieved. RESULTS: We recorded a complication rate of 40%, respectively sural nerve hypoesthesia (14.3%), delayed wound healing (28.6%), infection (20.9%) and re-rupture (4.8%). Surgical resident, as primary operating surgeon was associated with a higher complication rate (p = 0.042). Overall, a median functional ATRS score of 17 (IQR 6.5-39.5) was recorded. Infection was associated with significantly higher total healthcare costs per patient as compared to re-rupture (€17,435 vs. €4,537, p = 0.013). The total cost for surgical debridement (n = 6) was approximately 5-times higher than for re-rupture (n = 5), €108,382 vs. €22,272. The median ATRS score for surgical debridement after infection and re-rupture did not differ significantly from the overall ATRS score, respectively 32 (IQR 21-63) and 28 (IQR 15-28). Nevertheless, a difference of 10 points is considered clinically relevant. CONCLUSION: The overall functional outcome of open repair of Achilles tendon ruptures is rather good, however associated with a high complication rate, mainly due to wound problems and infection. Although several risk factors were identified, only the operating surgeon is modifiable. Considering the high total costs for surgical debridement in the context of infection compared to re-rupture surgery, despite equal functional outcome,we decided to change clinical practice to reduce the complication rate and healthcare costs. The outcome and precise costs for percutaneous repair will be addressed.

Are the current guidelines for surgical delay in hip fractures too rigid? A single center assessment of mortality and economics.

PURPOSE: Controversy remains around acceptable surgical delay of acute hip fractures with current guidelines ranging from 24 to 48 h. Increasing healthcare costs force us to consider the economic burden as well. We aimed to evaluate the adjusted effect of surgical delay for hip fracture surgery on early mortality, healthcare costs and readmission rate. We hypothesized that shorter delays resulted in lower early mortality and costs. METHODS: In this retrospective cohort study 2573 consecutive patients aged ≥50 years were included, who underwent surgery for acute hip fractures between 2009 and 2017. Main endpoints were thirty- and ninety-day mortality, total cost, and readmission rate. Multivariable regression included sex, age and ASA score as covariates. RESULTS: Thirty-day mortality was 5% (n = 133), ninety-day mortality 12% (n = 304). Average total cost was €11960, dominated by hospitalization (59%) and honoraria (23%). Per 24 h delay, the adjusted odds ratio was 1.07 (95% CI 0.98-1.18) for thirty-day mortality, 1.12 (95% CI 1.04-1.19) for ninety-day mortality, and 0.99 (95% CI = 0.88-1.12) for readmission. Per 24 h delay, costs increased with 7% (95% CI 6-8%). For mortality, delay was a weaker predictor than sex, age, and ASA score. For costs, delay was the strongest predictor. We did not find clear cut-points for surgical delay after which mortality or costs increased abruptly. CONCLUSIONS: Despite only modest associations with mortality, we observed a steady increase in healthcare costs when delaying surgery. Hence, a more pragmatic approach with surgery as soon as medically and organizationally possible seems justifiable over rigorous implementation of the current guidelines.