Improving fragility hip fracture care through data: a multicentre experience from a country with an emerging economy during the COVID-19 pandemic.

INTRODUCTION: In low-to-middle-income countries (LMIC), the orthogeriatric model of care is still in its early stages of development. This study describes the initial results of the first online fragility hip fracture database to be setup in the Philippines using a modified minimum common dataset to generate outcomes data based on current hospital practices. METHODS: A multicentre prospective cohort study among 12 Philippine hospitals was conducted from June 2020 to February 2021. Thirty-day mortality, morbidity and mobility were measured. Significant factors associated with mortality were determined. RESULTS: 158 elderly patients with fragility hip fractures were included in the study. Nine patients (5.7%) were confirmed or suspected to have COVID-19 infection. Median time of injury to admission was at least 3 days (IQR: 1.0-13.7). Overall, 80% of patients underwent surgical intervention with a median time from admission to surgery of at least 5 days (IQR: 2.5-13.6). Thirty-day mortality and morbidity rates for acute fragility fractures were 3.7%. Factors significantly associated with early mortality were poor prefracture mobility, COVID-19 infection, radiograph of the abnormal chest and conservative treatment. Non-surgical patients had no functional mobility or were wheelchair users and had a significantly higher morbidity rate than surgically treated patients (13.6% vs 1.8%; p=0.031). CONCLUSION: Despite treatment delays unique to an LMIC, short-term outcomes remain favourable for non-COVID-19 fragility hip fracture patients treated with surgery. Prompt admission and multidisciplinary care for elderly hip fracture patients while maintaining protective measures for COVID-19 infection control are recommended. The quality of data collected illustrates how this online database can provide a framework for a sustainable audit or registry as well as provide a platform for the introduction of orthogeriatric concepts at a multiregional scale.

Unplanned Excision of Soft Tissue Sarcomas of the Extremities in a Low-to-Middle-Income Country.

BACKGROUND: Outcomes of unplanned excisions of extremity soft tissue sarcomas (STSE) range from poor to even superior compared with planned excisions in developed countries. However, little is known regarding outcomes in low-to-middle-income countries. This study aimed to determine whether definitively treated STSE patients with a previous unplanned excision have poorer oncologic outcomes compared with those with planned excisions. PATIENTS AND METHODS: Using the database of a single sarcoma practice, we reviewed 148 patients with STSE managed with definitive surgery-78 with previous unplanned excisions (UE) and 70 with planned excisions (PE). RESULTS: Median follow-up was 4.4 years. UE patients had more surgeries overall and plastic reconstructions (P < 0.001). On multivariate analysis, overall survival (OS), local recurrence-free survival (LRFS), and distant metastasis-free survival (DMFS) were not worse among UE patients compared with PE patients. Negative predictors for LRFS were high tumor grade (P = 0.031) and an R1 surgical margin (P < 0.001). High grade (P <0.001), local recurrence (P = 0.001), and planned excisions (P = 0.009) predicted poorer DMFS, while age over 65 years (P = 0.011) and distant metastasis predicted poorer OS (P < 0.001). CONCLUSIONS: We recommend systematic re-excision for patients with unplanned excisions. Our study shows that STSE patients with UE, when subjected to re-excision with appropriate surgical margins, can achieve oncologic results similar to those for PE patients. However, there is an associated increased number of surgeries and plastic reconstruction for UE patients. This underscores the need, especially in a resource-limited setting, for education and collaborative policies to raise awareness about STSE among patients and physicians.

Outcomes After Abductor Reattachment to Proximal Femur Endoprosthesis After Tumor Resection.

INTRODUCTION: Resection of the proximal femur raises several challenges including restoration of the abductor mechanism. Few evaluated the outcomes of different techniques of abductor fixation to the proximal femur endoprosthesis. METHODS: A retrospective review of patients who underwent proximal femoral arthroplasty with a minimum follow-up of 12 months was conducted. Patients were divided into two groups: (1) those with preserved greater trochanter (GT) reattached to the implant and (2) those with direct abductor muscle reattachment. Both groups were compared for surgical and functional outcomes. Group 1 patients were subdivided into those who received GT reinsertion using grip and cables and those reattached using sutures. RESULTS: Fifty-three patients were included with a mean follow-up of 49 months. There were 22 patients with reinserted GT and 31 patients with soft-tissue repair. The endoprosthesis revision rate was comparable between groups (P = 0.27); however, the incidence of dislocations was higher in group 2 (0/22 versus 6/31; P = 0.035). Trendelenburg gait (77% versus 74%), use of walking aids (68% versus 81%), and abductor muscle strength were comparable between both groups (P > 0.05). In group 1, 15 patients had GT reinsertion with grip and cables. Of those, five patients (33%) had cable rupture within 13 months of follow-up. GT displacement reached 12 mm at 12 months of follow-up in patients with grip and cables compared with 26 mm in patients with GT suture reinsertion (P < 0.05). DISCUSSION: Although GT preservation did not improve functional outcomes, it was associated with a lower dislocation rate despite frequent cable failure. Less displacement was observed when GT reattachment used grip and cables.

Joint-sparing reconstruction for extensive periacetabular metastases: Literature review and a novel minimally invasive surgical technique.

Classically, patients with advanced lytic disease of the acetabulum secondary to metastatic bone disease are treated with complex arthroplasty reconstruction techniques. Advancements in percutaneous techniques have extended the indications for safer, minimally invasive procedures for patients with periacetabular metastasis without the need for complex hip replacement and the complications that follow it. The purpose of this report is to revisit the management of this group of patients and provide indications for an alternative minimally invasive joint-sparing technique. We describe a novel technique using a combination of percutaneous cryoablation, cementoplasty and two-screw fixation. With careful consideration of indications, excellent functional and oncologic outcomes one year after surgery is possible without the need for additional procedures.

Transoral approach using a tubular retractor system in the treatment of atlantoaxial Pott's disease: a novel method of surgical decompression.

The use of tubular retractors in minimally invasive spine surgery has been described extensively in the literature. However, there are only select reports discussing their use specifically in a transoral approach for upper cervical pathologies such as an epidural abscess and a dystrophic os odontoideum.We report the first use of a transtubular transoral approach in a rare case of an adult presenting with severe neck pain with progressing neurologic signs secondary to atlantoaxial Pott's disease. Debridement and partial odontoidectomy performed using this approach allowed less trauma to surrounding soft tissues without sacrificing an excellent visualisation of the operative field. A halo vest was applied to provide temporary stability. The patient transitioned out of his halo vest after 6 months while completing medical therapy after a year without need for further intervention. The transtubular transoral approach is a suitable alternative to the conventional approach in patients with atlantoaxial Pott's disease.