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.

Current Status and Advancements in Platelet-Rich Plasma Therapy.

Platelet-rich plasma (PRP) as a treatment modality has been around for the last four decades, but only truly gained popularity over the last 10 to 15 years in medicine, in a variety of fields ranging from regenerative medicine to infertility treatment. It has gained popularity, especially in treating musculoskeletal conditions where the bulk of research has been performed and published. There is level I evidence available supporting its efficacy in the treatment of osteoarthritis (OA), epicondylitis, bursitis, compressive neuropathy, plantar fasciitis, muscular injuries and osteochondral lesions. Most published research with regards to PRP has been focused on knee OA (limited research in shoulder, elbow, and foot and ankle OA), lateral epicondylitis and carpal tunnel syndrome, whereas spinal and hand conditions have limited research available. Tendinopathies and partial tendon tears have conflicting evidence available, with level I evidence supporting PRP's use in rotator cuff tendinopathies and tears, with contradictory level I evidence discouraging its use in patella and Achilles tendinopathies and tears. The available evidence regarding the use of PRP continues to produce conflicting results, but despite this, there is an ongoing increase in the popularity and use of PRP in patients with musculoskeletal conditions.

A Retrospective Study: Is Low-Intensity Pulsed Ultrasound (LIPUS) an Effective Alternate Treatment Option for Non-union?

Background There is ongoing controversy regarding the use of low-intensity pulsed ultrasound (LIPUS) therapy in patients with delayed union or non-union. Exogen (Bioventus, Durham, NC) is a well-known brand of LIPUS, and according to their data, 86% of non-union fractures will heal without the need for surgery. A few independent retrospective studies reported much lower healing rates. Method A retrospective observational study was performed assessing all the patients who underwent Exogen therapy in a single centre. All patients who were initiated on Exogen after three months with radiographic signs of the delayed union were included in the study. Routine follow-up appointments were organised until clinical and radiological healing could be confirmed. Daily 20-minute Exogen sessions were continued until the fracture was healed or up to a maximum of four months as recommended by the manufacturer. Results A total of 37 patients received Exogen therapy from 2012 to 2021, of which only 28 patients met our inclusion criteria and were subsequently analysed. The mean age of the patients was 52.0 (SD ± 20.2) with a male to female ratio of 1.7:1. The average time to healing was 115 (±51.2) days with a success rate of 82.14%. The average interfragmentary gap was 7.5 mm (±5.8) for the fractures that healed whereas the failed treatment was 16.1 mm (±13.8). There was no obvious association between outcomes after Exogen therapy and the patient's age, sex, time to initiate Exogen, diabetes, and smoking status. Conclusion This study demonstrated a high success rate of LIPUS therapy for patients with delayed union and non-union. LIPUS represents a safe, non-invasive alternative to revision surgery. An independent risk factor for a potentially poor outcome is an increased interfragmentary gap.

A Description of Novel Uses of Hip Protectors in an Elderly Hip Fracture Population: A Technical Report.

Hip fractures are a significant cause of morbidity and mortality in the elderly population. The number of hip fractures is set to increase significantly by 2050 as the global population ages. The costs associated with hip fracture patients are significant due to prolonged hospitalisation and rehabilitation. Hip protectors have been advocated as a strategy to reduce the risk of hip fractures in a high-risk population. Evidence suggests that hip protectors are a cost-effective method for reducing the risk of hip fractures. There have, however, been issues with adherence with wearing hip protectors amongst patients and healthcare staff. Despite prevention strategies, many patients continue to present with hip fractures. Many of these patients have cognitive impairment or experience peri-operative delirium. This can cause issues with patients' interference with the operative wound and presents a significant burden to the healthcare team with the need for increased wound monitoring and care in the post-operative period. Applying a well-fitted hip protector provides a substantial additional barrier to protect the surgical wound. Hip fracture surgical wounds can be difficult to manage in these patients and our standard post-operative protocol is to apply compression dressings in this group of patients. We have found that a well-fitted hip protector can provide adequate compression to the surgical site. We describe a brief technical report on a novel use of hip protectors in providing wound security in the agitated patient post-operatively as well as a method of providing compression to the surgical wound site.

Incidence of Fat Embolism Syndrome in Femur Fractures and Its Associated Risk Factors over Time-A Systematic Review.

BACKGROUND: Fat embolism (FE) continues to be mentioned as a substantial complication following acute femur fractures. The aim of this systematic review was to test the hypotheses that the incidence of fat embolism syndrome (FES) has decreased since its description and that specific injury patterns predispose to its development. MATERIALS AND METHODS: Data Sources: MEDLINE, Embase, PubMed, and Cochrane Central Register of Controlled Trials databases were searched for articles from 1 January 1960 to 31 December 2019. STUDY SELECTION: Original articles that provide information on the rate of FES, associated femoral injury patterns, and therapeutic and diagnostic recommendations were included. DATA EXTRACTION: Two authors independently extracted data using a predesigned form. STATISTICS: Three different periods were separated based on the diagnostic and treatment changes: Group 1: 1 January 1960-12 December 1979, Group 2: 1 January 1980-1 December 1999, and Group 3: 1 January 2000-31 December 2019, chi-square test, χ2 test for group comparisons of categorical variables, p-value < 0.05. RESULTS: Fifteen articles were included (n = 3095 patients). The incidence of FES decreased over time (Group 1: 7.9%, Group 2: 4.8%, and Group 3: 1.7% (p < 0.001)). FES rate according to injury pattern: unilateral high-energy fractures (2.9%) had a significantly lower FES rate than pathological fractures (3.3%) and bilateral high-energy fractures (4.6%) (p < 0.001). CONCLUSIONS: There has been a significant decrease in the incidence of FES over time. The injury pattern impacts the frequency of FES. The diagnostic and therapeutic approach to FES remains highly heterogenic to this day.

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.

The Utility of a Plain Film Arthrogram to Confirm Acute Liner Dissociation in the Setting of Primary Total Hip Arthroplasty.

Acute Liner dissociation is a well-documented, but uncommon complication of total hip arthroplasty, yet the journey to diagnosis remains undefined. This clinical case report outlines the use of plain film arthrogram for diagnosis in a 53-year-old female who presented to the ED following a fall, describing symptoms of increasing groin pain, reduced range of movement, difficulty weight-bearing and a grinding sensation in her left hip, all on a background of total hip replacement two years ago. Examination revealed impaired flexion, rotation and abduction while AP pelvic X-ray confirmed mild eccentric placement of the femoral head, and lateral X-ray proved joint enlocation. An arthrogram of the left hip was performed the following day with injection of 4mls of iodinated contrast injected into the joint. Inferior dissociation of the liner from the shell was evident. The femoral head and liner were replaced two days later, and the liner was found to have shearing and gross plastic deformation at the rim. The patient reported immediate relief from the groin pain and was discharged on the fourth day postoperatively. This shows how plain film imaging fails in diagnosing acute liner dissociation dynamic fluoroscopic tests, post-arthrography CT and metal artifact reduction sequence magnetic resonance imaging (MARS MRI) have previously been proposed despite their associated wait-time, radiation exposure and financial costs. This case report highlights the role of plain film arthrography as a low risk and low-cost diagnostic tool. The report also suggests the incorporation of radio-dense markers in liners to facilitate the use of arthrography when diagnosing dissociation, also raising awareness of prevention and recognition in what may be an under-reported complication of hip arthroplasty.

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.

Inter- and intraobserver agreement of three classification systems for lateral clavicle fractures - reliability comparison between two specialist groups.

BACKGROUND: Although of great value in the management of lateral clavicle fractures, substantial variation in their classification exists. We performed a retrospective study to address the inter- and intraobserver reliability of three different classification systems for lateral clavicle fractures. METHODS: Radiographs of 20 lateral clavicle fractures that represented a full spectrum of adult fracture patterns were graded by five experienced radiologists and five experienced trauma surgeons according to the Orthopaedic Trauma Association (OTA), the Neer, and the Jäger/Breitner classification systems. This evaluation was performed at two different time points separated by 3 months. To measure the observer agreement, the Fleiss kappa coefficient (κ) was applied and assessed according to the grading of Landis and Koch. RESULTS: The overall interobserver reliability showed a fair agreement in all three classification systems. For the OTA classification system, the interobserver agreement showed a mean kappa value of 0.338 ranging from 0.350 (radiologists) to 0.374 (trauma surgeons). Kappa values of the interobserver agreement for the Neer classification system ranged from 0.238 (trauma surgeons) to 0.276 (radiologists) with a mean κ of 0.278. The Jäger/Breitner classification system demonstrated a mean kappa value of 0.330 ranging from 0.306 (trauma surgeons) to 0.382 (radiologists).The overall intraobserver reliability was moderate for the OTA and the Jäger/Breitner classification systems, while the overall intraobserver reliability for the Neer classification system was fair.The kappa values of the intraobserver agreements showed, in all classification systems, a wide range with the OTA classification system ranging from 0.086 to 0.634, the Neer classification system ranging from 0.137 to 0.448, and a range from 0.154 to 0.625 of the Jäger/Breitner classification system. CONCLUSIONS: The low inter- and intraobserver agreement levels exhibited in all three classification systems by both specialist groups suggest that the tested lateral clavicle fracture classification systems are unreliable and, therefore, of limited value. We should recognize there is considerable inconsistency in how physicians classify lateral clavicle fractures and therefore any conclusions based on these classifications should be recognized as being somewhat subjective.

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.

Magnetic Resonance Imaging Features of Traumatic Patellofemoral Dislocation.

Acute traumatic patellar dislocations are encountered with relative frequency, making up 3% of all knee injuries. Typically witnessed in younger patients following sporting injuries, this injury can be debilitating, potentially leading to recurrent dislocation, pain, reduction in activity and patellofemoral osteoarthritis. Management of this injury remains controversial, and as such detailed magnetic resonance imaging (MRI) is increasingly recommended to help illustrate the exact nature of osteochondral and soft tissue injury, with a view to assessing the anatomical sequelae of patellar dislocation as well as the potential of recurrence and dictating the need for either conservative or surgical management in the acute setting. As such, awareness of the typical MRI findings in traumatic patellar dislocations may potentially aid in pursuing appropriate intervention for this pathology. This case describes a 33-year-old gentleman presenting to the emergency department following patellar dislocation. After failed departmental closed reduction, this patient progressed on to definitive anatomical MRI assessment followed by acute surgical intervention in the form of medial patellofemoral ligament (MPFL) repair. This case allows for both illustration and discussion of typical radiological features associated with traumatic patellar dislocation.

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.

The Use of WhatsApp Smartphone Messaging Improves Communication Efficiency within an Orthopaedic Surgery Team.

INTRODUCTION: Effective and timely communication is important for any surgical specialty to function. The use of smartphones is prevalent amongst doctors. Numerous smartphone applications offer the potential for fast and cost-effective communication. WhatsApp is a commonly used application that is free, easy to use, and capable of text and multimedia messaging. We report on the use of WhatsApp over a six month period in our unit. MATERIALS AND METHODS: WhatsApp communication between non-consultant members of an orthopaedic team over a six-month period was analysed. Both the phones and the WhatsApp application were password-protected, and patient details were anonymised. A series of 20 communications using the hospital pager system and the telephone system were also analysed. RESULTS: A total of 5,492 messages were sent during the six-month period and were part of 1,916 separate communication events. The vast majority of messages, 5,090, were related to patient care. A total of 195 multimedia messages were sent and these included images of radiographs and wounds. When using the hospital telephones, the length of time spent on a communication averaged 5.78 minutes and using the hospital pager system averaged 7.45 minutes. Using the WhatsApp messaging system has potentially saved up to 7,664 minutes over the study period. All participants found WhatsApp easy to use and found it to be more efficient than the traditional pager system Conclusion: Compared to the traditional pager systems, the use of WhatsApp is easy, inexpensive, and reliable and can help improve the efficiency of communication within a surgical team.