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.

Artificial intelligence in orthopaedics: can Chat Generative Pre-trained Transformer (ChatGPT) pass Section 1 of the Fellowship of the Royal College of Surgeons (Trauma & Orthopaedics) examination?

PURPOSE: Chat Generative Pre-trained Transformer (ChatGPT) is a large language artificial intelligence (AI) model which generates contextually relevant text in response to questioning. After ChatGPT successfully passed the United States Medical Licensing Examinations, proponents have argued it should play an increasing role in medical service provision and education. AI in healthcare remains in its infancy, and the reliability of AI systems must be scrutinized. This study assessed whether ChatGPT could pass Section 1 of the Fellowship of the Royal College of Surgeons (FRCS) examination in Trauma and Orthopaedic Surgery. METHODS: The UK and Ireland In-Training Examination (UKITE) was used as a surrogate for the FRCS. Papers 1 and 2 of UKITE 2022 were directly inputted into ChatGPT. All questions were in a single-best-answer format without wording alterations. Imaging was trialled to ensure ChatGPT utilized this information. RESULTS: ChatGPT scored 35.8%: 30% lower than the FRCS pass rate and 8.2% lower than the mean score achieved by human candidates of all training levels. Subspecialty analysis demonstrated ChatGPT scored highest in basic science (53.3%) and lowest in trauma (0%). In 87 questions answered incorrectly, ChatGPT only stated it did not know the answer once and gave incorrect explanatory answers for the remaining questions. CONCLUSION: ChatGPT is currently unable to exert the higher-order judgement and multilogical thinking required to pass the FRCS examination. Further, the current model fails to recognize its own limitations. ChatGPT's deficiencies should be publicized equally as much as its successes to ensure clinicians remain aware of its fallibility.

Magnetic Resonance Imaging in the Management of Significantly Displaced Adolescent Posterior Sternoclavicular Joint Injuries.

BACKGROUND: Computed tomography (CT) scans are the standard imaging modality for the diagnosis and treatment guide for adolescent posterior sternoclavicular joint (SCJ) injuries. However, the medial clavicular physis is not visualized and it is not possible to differentiate between a true SCJ dislocation and a physeal injury (PI). An magnetic resonance imaging (MRI) scan can visualize the bone and the physis. METHODS: We treated a series of patients with adolescent posterior SCJ injuries diagnosed on CT scan. Patients underwent an MRI scan to differentiate between a true SCJ dislocation and a PI and to further differentiate between a PI with or without residual medial end clavicular bone contact. Patients with a true SCJ dislocation and a PI with no contact underwent an open reduction and fixation. Patients with a PI with contact were treated nonoperatively with repeat CT scans at 1 and 3 months. At final follow-up SCJ clinical function was assessed using Quick-DASH, Rockwood, modified Constant, and single assessment numeric evaluation (SANE) scores. RESULTS: Thirteen patients (2 female and 11 male) with an average age of 14.9 years (12 to 17) were included in the study. Twelve patients were available at final follow-up (mean 50 mo, 26 to 84). One patient had a true SCJ dislocation and 3 had an off-ended PI and were treated with an open reduction and fixation. Eight patients had a PI with residual bone contact and were treated nonoperatively. For these patients serial CT scans showed that the position was maintained, with a serial increase in callus formation and bone remodeling. The average follow-up was 42.9 months (24 to 62). At final follow-up the mean Quick-disabilities of the arm, shoulder and hand (DASH) was 0.4 (0 to 2.3), Rockwood was 15, modified Constant was 98.8 (89 to 100) and SANE was 99.5% (95 to 100). CONCLUSION: In this case series of significantly displaced adolescent posterior SCJ injuries MRI scans allowed identification of true SCJ dislocations and off-ended PIs, which were successfully treated by open reduction, and PIs with residual physeal contact which were successfully treated nonoperatively. LEVEL OF EVIDENCE: Level IV-case series.

Causes and associations with mortality in patients with pelvic ring injuries with haemorrhagic shock.

BACKGROUND: High energy pelvic ring injuries are associated with significant morbidity and mortality and can be accompanied by haemorrhagic shock following associated vascular injury. This study evaluated the causes and predictors of mortality in haemodynamically unstable pelvic fractures. METHODS: This retrospective observational study at a Major Trauma Centre reviewed 938 consecutive adult patients (≥ 18yrs) with pelvic ring injuries between December 2014 and November 2018. Patients with features of haemorrhagic shock were included, defined as: arrival Systolic BP < 90 mmHg, Base Deficit ≥ 6.0 mmol/l, or transfusion of ≥ 4 units of packed red blood cells within 24 h. RESULTS: Of the 102 patients included, all sustained injuries from high energy trauma, and 47.1% underwent a haemorrhage control intervention (Resuscitative Endovascular Balloon Occlusion of the Aorta-REBOA, Interventional Radiology-IR, or Laparotomy). These were more often required following vertical shear injuries (OR 10.7, p = 0.036). Overall, 33 patients (32.4%) died; 16 due to a head injury, and only 2 directly from acute pelvic exsanguination (6.1%). Multivariable logistic regression demonstrated that increasing age, Injury Severity Score, Abbreviated Injury Scale (AIS) Head ≥ 3 and open pelvic fracture were all independent predictors of mortality, and IR was associated with reduced mortality. Lateral Compression III (LC3) injuries were associated with mortality due to multiple organ dysfunction syndrome (MODS). CONCLUSION: Haemodynamically unstable patients with pelvic ring injuries have a high mortality rate, but death is usually attributed to other injuries or later complications, and not from acute exsanguination. This reflects improvements in resuscitative care, transfusion protocols, and haemorrhage control techniques.

Virtual fracture clinics: be vigilant for the ligamentous elbow injury.

The Covid-19 pandemic encouraged remote healthcare and led to dependency on virtual fracture clinics (VFC). VFC are orthopaedic consultant-led clinics where cases are reviewed virtually following referral by emergency department clinicians. Success is contingent on a comprehensive initial history and examination. This pathway has high patient satisfaction rates and cost-saving benefits. However, clinicians must be vigilant for high-energy mechanisms or examination findings suggestive of greater underlying injury. In this case, VFC missed a rare ipsilateral annular ligament injury in a 15-year old with an undisplaced radial neck fracture, following a fall from a horse. This led to radial head dislocation and delayed surgical repair. Untreated, radial head dislocations lead to pain and reduced range of movement. Despite the rarity of this injury pattern, face-to-face orthopaedic examination would have raised concern for significant ligamentous injury. A high-energy mechanism of injury mandates face-to-face senior orthopaedic review to avoid missing serious concomitant injury.

Epidemiology of pelvic and acetabular fractures across 12-mo at a level-1 trauma centre.

BACKGROUND: Despite motor-vehicle safety advancements and increasingly rigorous workplace safety regulations, trauma/suicide remains the leading cause of death under the age of 45 in the United Kingdom. To promote centralisation of care and optimisation of major trauma outcomes, in 2012 the National Health Service introduced the Trauma Network System. To our knowledge, this is the first study to analyse the epidemiology of pelvic and acetabular trauma over a one-year period at a level-1 trauma centre in the United Kingdom, since nationwide introduction of the Trauma Network System. AIM: To characterize the epidemiology of high-energy pelvic and acetabular fractures over a one-year period at a level-1 trauma centre, and explore both resources required to care for these patients and opportunities for future research and injury prevention initiatives. METHODS: 227 consecutive patients at a level-1 trauma centre with pelvic and acetabular fractures were analysed between December 2017-December 2018. Paediatric patients (< 18 years) and fragility fractures were excluded, leaving 175 patients for inclusion in the study. Statistical analysis was performed using Fisher's exact test for categorical variables. RESULTS: 72% of pelvic and acetabular fractures occurred in male patients at a median age of 45 years. 15% were the result of a suicide attempt. 48% of patients required pelvic or acetabular surgery, with 38% undergoing further surgery for additional orthopaedic injuries. 43% of patients were admitted to intensive care. The median inpatient stay was 13 days, and the 30- day mortality was 5%. Pelvic ring trauma was more commonly associated with abdominal injury (P = 0.01) and spine fractures (P < 0.001) than acetabular fractures. Vertical shear pelvic ring fractures were associated with falls (P = 0.03) while lateral compression fractures were associated with road traffic accidents (P = 0.01). CONCLUSION: High energy pelvic and acetabular fractures are associated with concomitant orthopaedic fractures (most commonly spine and lower limb), intensive care admission and prolonged inpatient stays. Most pelvic ring injuries secondary to road traffic accidents are lateral compression type, demonstrating the need for future research to drive advancements in lateral impact vehicle safety along with mental health surveillance for those deemed to be potential suicide risks.

Range of Movement and Patient-Reported Outcomes in Shoulder Arthroplasty in the Elderly: A Comparison of Anatomical Versus Reverse Shoulder Replacements.

Introduction Shoulder arthroplasty is in increasing demand in the elderly given the rising prevalence of glenohumeral osteoarthritis (OA) across the population. There is a dearth of evidence in the current literature comparing anatomical total shoulder arthroplasty and reverse total shoulder arthroplasty (RTSA) in the elderly population. This study compares patient-reported outcome measures and range of movement (ROM) between anatomical and reverse total shoulder replacements in matched patient cohorts over the age of 70 years. Materials and methods This retrospective cohort study compares range of movement and patient-reported outcomes between anatomical total shoulder arthroplasty and reverse total shoulder arthroplasty in matched cohorts over the age of 70 years at a single institution between 2011 and 2015. Overall, 75 patients were recruited, including 44 patients with anatomical total shoulder arthroplasty and 31 patients with reverse total shoulder arthroplasty. Cohorts were matched according to age, preoperative Oxford Shoulder Score (OSS), and preoperative range of movement. The minimum clinical follow-up was one year. Results At one year, range of movement metrics in flexion, abduction, and external rotation all demonstrated greater improvements in the anatomical total shoulder arthroplasty cohort in comparison to the reverse total shoulder arthroplasty cohort (p<0.0001). No statistical difference in Oxford Shoulder Score was evident between cohorts. Conclusion Anatomical total shoulder arthroplasty demonstrates a significant improvement in range of movement in comparison to reverse total shoulder arthroplasty in matched elderly patient cohorts. However, there was no statistical difference in functional assessment scores between reverse shoulder replacement and anatomical shoulder replacement.

Evidence-based approach to providing informed consent for hip fracture surgery during the COVID-19 era.

BACKGROUND: Hip fractures are the most common reason for inpatient orthopaedic trauma admission. Urgent surgical intervention for hip fractures has remained a clinical priority throughout the coronavirus disease 2019 (COVID-19) pandemic. Despite this, there is a paucity of clinical guidance addressing the informed consent process for hip fracture surgery in COVID-19 positive patients. This is of paramount medicolegal importance in a high-risk patient population. AIM: To quantify the additional perioperative risks for COVID-19 positive patients undergoing hip fracture surgery and provide clinicians with an evidence-based framework to establish an informed consent process. METHODS: Two hundred and fifty nine consecutive patients undergoing surgical intervention for hip fractures in four hospitals in the United Kingdom were recruited. 51 patients were confirmed positive for COVID-19. Predefined outcomes were analyzed over a 30-d postoperative period. COVID-19 positive and COVID-19 negative patients were compared after adjustment for confounding factors. RESULTS: COVID-19 positive patients had more intensive care admissions (27% vs 5%, P < 0.001), longer inpatient stays (median 23 d vs 9 d, P < 0.001) and a higher 30-d mortality (29% vs 10%, P = 0.001) than COVID-19 negative patients. Postoperative complications were evident in 74.5% of COVID-19 positive patients. 35.3% of COVID-19 positive patients suffered postoperative lower respiratory tract infections with 13.7% developing acute respiratory distress syndrome (ARDS) and 9.8% experiencing symptomatic thromboembolic events. CONCLUSION: The COVID-19 pandemic has created uncertainty in the medical community worldwide and poses unique challenges in providing informed consent for surgery. COVID-19 positive patients undergoing hip fracture surgery should be consented for the additional risk of postoperative complications (including lower respiratory tract infection, ARDS, deep vein thrombosis and pulmonary embolism), increased requirement for intensive care admission, longer inpatient stay and higher risk of mortality. Further, clinicians must be transparent about the potential for unknown risks as research into the long-term surgical outcomes of COVID-19 positive patients continues to evolve.

The effects of COVID-19 on perioperative morbidity and mortality in patients with hip fractures.

AIMS: During the COVID-19 pandemic, many patients continue to require urgent surgery for hip fractures. However, the impact of COVID-19 on perioperative outcomes in these high-risk patients remains unknown. The objectives of this study were to establish the effects of COVID-19 on perioperative morbidity and mortality, and determine any risk factors for increased mortality in patients with COVID-19 undergoing hip fracture surgery. METHODS: This multicentre cohort study included 340 COVID-19-negative patients versus 82 COVID-19-positive patients undergoing surgical treatment for hip fractures across nine NHS hospitals in Greater London, UK. Patients in both treatment groups were comparable for age, sex, body mass index, fracture configuration, and type of surgery performed. Predefined perioperative outcomes were recorded within a 30-day postoperative period. Univariate and multivariate analysis were used to identify risk factors associated with increased risk of mortality. RESULTS: COVID-19-positive patients had increased postoperative mortality rates (30.5% (25/82) vs 10.3% (35/340) respectively, p < 0.001) compared to COVID-19-negative patients. Risk factors for increased mortality in patients with COVID-19 undergoing surgery included positive smoking status (hazard ratio (HR) 15.4 (95% confidence interval (CI) 4.55 to 52.2; p < 0.001) and greater than three comorbidities (HR 13.5 (95% CI 2.82 to 66.0, p < 0.001). COVID-19-positive patients had increased risk of postoperative complications (89.0% (73/82) vs 35.0% (119/340) respectively; p < 0.001), more critical care unit admissions (61.0% (50/82) vs 18.2% (62/340) respectively; p < 0.001), and increased length of hospital stay (mean 13.8 days (SD 4.6) vs 6.7 days (SD 2.5) respectively; p < 0.001), compared to COVID-19-negative patients. CONCLUSION: Hip fracture surgery in COVID-19-positive patients was associated with increased length of hospital stay, more admissions to the critical care unit, higher risk of perioperative complications, and increased mortality rates compared to COVID-19-negative patients. Risk factors for increased mortality in patients with COVID-19 undergoing surgery included positive smoking status and multiple (greater than three) comorbidities. Cite this article: Bone Joint J 2020;102-B(9):1136-1145.

The role of anterolateral augmentation in primary ACL reconstruction.

The anterolateral soft tissue envelope of the knee has long been recognised as a key stabilising structure. Once the mainstay of operative management of anterior cruciate ligament (ACL) rupture, interest in the area fell away with the advent of intraarticular arthroscopic reconstruction. Renewed interest in these structures together with cadaveric data evidencing the potential for restoration of near normal knee biomechanics following ACL and anterolateral soft tissue reconstruction has driven current concepts and development of operative techniques. Options for current anterolateral augmentation techniques in primary ACL reconstruction plus patient selection considerations are reviewed, together with an outlook at future research key to development of this area.

Dual mobility in primary total hip arthroplasty: current concepts.

Total hip arthroplasty (THA) is one of the most successful surgical procedures - reducing pain and providing functional improvement. However, THA instability is a disabling condition and remains the most common indication for revision THA. To combat the risk of instability, the concept of dual mobility (DM) was developed. This article provides a comprehensive review of DM in the literature.Widespread use of first-generation DM was limited due to concern regarding wear of the polyethylene head and the unique complication of intraprosthetic dislocation (IPD). Implant modifications using highly cross-linked, durable polyethylene and a smooth, cylindrical femoral neck have all but eliminated IPD in contemporary DM.In multiple studies, DM demonstrates statistically significant reductions in dislocation rates comparative to standard bearing primary THA. These results have been particular promising in high-risk patient populations and femoral neck fractures - where low dislocation rates and improved functional outcomes are a recurrent theme. From an economic perspective, DM is equally exciting - with lower accrued costs and higher accrued utility comparative to standard bearing THA.Longer-term clinical evidence and higher-quality prospective comparative studies are required to strengthen current research. Dual mobility may well represent the future gold standard for THA in high-risk patient populations and femoral neck fractures, but due diligence of long-term performance is needed before recommendations for widespread use can be justified. Cite this article: EFORT Open Rev 2019;4:640-646. DOI: 10.1302/2058-5241.4.180089.

Unicompartmental knee replacement - Current perspectives.

Unicompartmental knee replacement (UKR) is an effective treatment for end-stage, symptomatic unicompartmental osteoarthritis of the knee. However, certain aspects of the procedure are still debated. These areas of discussion include patient selection criteria, implant design and the discrepancy in survival rates between national registries and independent case series. These may contribute in limiting the more widespread acceptance of unicompartmental knee replacement. The aim of this paper is to review the up-to-date evidence on UKR and discuss the most relevant controversies regarding this procedure.

Patellofemoral arthroplasty: Current concepts.

Isolated patellofemoral arthritis (IPA) is a debilitating condition characterised by a loss of articular cartilage on the patella facets, the trochlear groove or both. By definition, patients with IPA must have normal cartilage in the tibiofemoral compartments of their knee. It is therefore logical to pursue arthroplasty which corrects the abnormality while sparing healthy bone and preserving the knee's native kinematics, which is the premise underpinning patellofemoral arthroplasty (PFA). However, its use remains controversial, with many surgeons still favouring total knee replacement (TKR) in these patients. This paper provides a comprehensive review of PFA in the literature to date and concludes, in carefully selected patients, PFA is worthy of consideration as a functionally superior and economically beneficial joint-preserving procedure - delaying TKR until implant failure or tibiofemoral osteoarthritis progression.