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.

Identifying Preoperative Predictors for 24-Hour Discharge After Elective Hip and Knee Arthroplasties.

Introduction The resumption of elective medical services post-pandemic has brought to the forefront the importance of outpatient arthroplasty services in promoting efficiency and mitigating hospital-acquired infections. This study aimed to identify preoperative factors that predict the success of outpatient lower limb arthroplasty surgeries. Methods Our investigation involved a retrospective review of 606 patients who underwent elective hip and knee arthroplasty. We documented variables such as the hospital length of stay, patient demographics (age and gender), Oxford Joint Scores, body mass index, socioeconomic status, American Society of Anaesthesiologists' (ASA) physical status classification, comorbid conditions, the Functional Comorbidity Index (FCI), preoperative blood test results, implant types, scheduling details of the surgery, and rates of readmission within 30 days post-surgery. A two-step analysis using univariate and multivariate regression models was performed to pinpoint preoperative indicators that could predict same-day discharge following arthroplasty. Results Forty-five patients (7.4%) were discharged within 24 hours of surgery. Early discharge did not correlate with higher rates of readmission within 30 days (p>0.05). Neither weekend nor afternoon surgeries significantly extended the length of stay beyond 24 hours (p>0.05). No significant differences in the prevalence of comorbidities, FCI scores, socioeconomic status, or preoperative blood test results were found when comparing patients discharged within 24 hours to those who stayed longer. Multivariate analysis revealed that patients younger than 65 years (relative risk (RR) 2.41; 95% confidence interval (CI) 1.02-5.74) and those receiving partial knee arthroplasty (RR 8.91; 95% CI 3.05-26.04) were more likely to be discharged within 24 hours. Conclusions Outpatient arthroplasty is a viable option, especially for individuals younger than 65 years undergoing partial knee arthroplasty, independent of other patient-related factors, comorbidities, and specifics of the hospital episode.

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.

Covid-19: Exploring medico-legal perceptions amongst orthopaedic surgeons and lawyers.

INTRODUCTION: British national guidelines and laws published by the British Orthopaedic Association and the new Coronovirus Act 2020 favoured treatment of trauma and orthopaedic conditions with non-operative alternatives.A survey was developed for both lawyers and trauma and orthopaedic clinicians to gauge their perceptions on guidelines related to protection of trauma and orthopaedic staff, and on prosecution with respect to future claims. MATERIAL AND METHODS: Sixteen questions were designed for surgeons and 11 questions for lawyers. The level of experience and career stages were explored in other questions. A Likert scale (0-5) was used to capture these perceptions. RESULTS: Clinicians envisaged themselves being less protected (mean = 2.6), forecasted a rise in negligence claims (mean = 3.4) and perceived little additional beneficial indemnity influence from the NHS (mean = 1.8). Lawyers felt that public perception would have more influence in negligence claim rates (mean = 2.6) and disapproved of complete immunity for clinicians (mean = 0.5). Disparities between different trauma and orthopaedic grades demonstrated sentiments of comfort with redeployment, preparedness in non-orthopaedic training and protection from litigation. DISCUSSION: The results reflected the overall anxiety over litigation reprisal shared amongst trauma and orthopaedic staff. Issues with providing sub-optimal care can worsen this overall fear. Feeling unprotected from litigation reprisal can leave clinicians with an additional sense of emotional and professional burden. Redeployment into unfamiliar environments can leave senior clinicians in limbo in contrast to their juniors. CONCLUSION: Non-surgical options to treat orthopaedic conditions affect both patients and trauma and orthopaedic staff. Feedback from lawyers reassures trauma and orthopaedic clinicians that negligence claims should not rise due to the updated national guidelines.

Anthropometric method for estimating component sizes in total hip arthroplasty.

BACKGROUND: Preoperative templating is essential in total hip arthroplasty (THA) as it not only helps to facilitate the correct implant type and size but also determines the post-operative biomechanics. Templating is also increasingly important from a medico-legal perspective and recommended in the British Orthopaedic Association Guide to Good Practice. Although templating has become increasingly digitised, there are no simple anthropometric models to predict implant sizes in the absence of digital methods. AIM: To assess the accuracy of using an easily obtainable measurement (shoe size) to predict component sizes in THA compared with digital templating. METHODS: Digital radiographs from a cohort of 102 patients (40 male, 62 female) who had undergone uncemented or hybrid THA at a single centre were retrospectively templated to desired cup and stem sizes using TraumaCad ® . We compared the templated size to the actual size of the implant and assessed if there was any correlation with the patient's shoe size. RESULTS: Statistically significant positive correlations were observed between: shoe size and templated cup size (ρ = 0.92, P < 0.001); shoe size with implanted cup size (ρ = 0.71, P < 0.001); shoe size and templated stem size (ρ = 0.87, P < 0.001); and shoe size with implanted stem size (ρ = 0.57, P < 0.001). Templated and implanted acetabular cup sizes were positively correlated (ρ = 0.76, P < 0.001) and were exact in 43.1% cases; 80.4% of implanted cup sizes were within 1 size (+/- 2 mm) of the template and 100% within 2 sizes (+/- 4 mm). Positive correlation was also demonstrated between templated and implanted femoral stem sizes (ρ = 0.69, P < 0.001) and were exact in 52.6% cases; 92.6% were within 1 size of the template and 98% within 2 sizes. CONCLUSION: This study has shown there to be a significant positive correlation between shoe size and templated size. Anthropometric measurements are easily obtainable and can be used to predict uncemented component sizes in the absence of digital methods.

Osteochondral Fractures After Patellar Dislocation: Current Concepts.

Osteochondral fractures of the knee occur frequently after acute patellar subluxation or dislocation. They can be challenging to manage because of the difficulty in diagnosing and treating these injuries in a timely fashion, in addition to choosing the optimum fixation method. This review presents the background, considerations for patient evaluation, and the best treatment options available for osteochondral fractures.

Is Surgical Training Prepared for the "Second Wave" of COVID-19? A Collaborative Perspective.

Restructuring of surgical services during the 'first wave' of the coronavirus-disease 2019 pandemic led to significant disruption in surgical learning opportunities provided to junior surgeons. Recent challenges faced by trainees have never been faced before. These include disruption to surgical opportunities available, completing assessments and attending educational events. With a 'second wave' now upon the United Kingdom it is vitally important we reflect upon the 'first wave' to ensure junior surgeons are able to achieve appropriate surgical case numbers, complete assessments and progress to the next stage of training. Alternate assessment methods in the United Kingdom need to be considered should the pandemic continue and clear information should be provided to surgical trainees regarding career progression. These are difficult times for surgical training and we need to endeavor that trainees are provided with opportunities similar to their predecessors albeit in difficult circumstances. This is to ensure the future standard of surgical patient care remains of the highest standard.

The incidence of venous thromboembolism in total joint replacement during COVID-19 pandemic: has lockdown had an influence?

AIMS: As the first wave of the COVID-19 pandemic began to dip, restarting elective orthopaedics became a challenge. Protocols including surgery at 'green' sites, self-isolation for 14 days, and COVID-19 testing were developed to minimize the risk of transmission. In this study, we look at risk effects of 14-day self-isolation on the incidence of venous thromboembolism (VTE) in our green site hospital among patients undergoing total joint replacement (TJR). METHODS: This retrospective cohort study included 50 patients who underwent TJR. Basic demographic data was collected including, age, sex, American Society of Anesthesiologists (ASA) grade, body mass index (BMI), type of surgery, and complications at two and four weeks. Univariate and multivariate analysis were used to identify risk factors associated with an increased risk of VTE. RESULTS: A total of 50 patients were included in our study, with 24 males and 26 females. The mean age was 67.86 (SD 11.803). Overall, 8% of patients suffered a VTE complication; symptomatic non-fatal pulmoary embolism was confirmed in 6% of patients (n = 3) as an inpatient, and symptomatic deep vein thrombosis was diagnosed in 2% of patients (n = 1) within two weeks of their operation. All patients were found to be female (p < 0.001), had a BMI > 30 (p = 0.317), and were immobile prior to their operation using walking aids (p = 0.016). CONCLUSION: The incidence we report is much higher than the reported incidence in the literature, which we believe is related to the 14-day self-isolation period and immobility prior to their operation. We recommend that all patients undergoing TJR that require a period of self-isolation, are pre-assessed prior to self-isolation for their risk of VTE, potentially using mechanical and chemical prophylaxis to reduce the likelihood of developing VTE.Cite this article: Bone Jt Open 2020;1-12:751-756.

How useful are virtual fracture clinics?: a systematic review.

BACKGROUND: Due to the overwhelming demand for trauma services, resulting from increasing emergency department attendances over the past decade, virtual fracture clinics (VFCs) have become the fashion to keep up with the demand and help comply with the BOA Standards for Trauma and Orthopaedics (BOAST) guidelines. In this article, we perform a systematic review asking, "How useful are VFCs?", and what injuries and conditions can be treated safely and effectively, to help decrease patient face to face consultations. Our primary outcomes were patient satisfaction, clinical efficiency and cost analysis, and clinical outcomes. METHODS: We performed a systematic literature search of all papers pertaining to VFCs, using the search engines PubMed, MEDLINE, and the Cochrane Database, according to the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) checklist. Searches were carried out and screened by two authors, with final study eligibility confirmed by the senior author. RESULTS: In total, 21 records were relevant to our research question. Six orthopaedic injuries were identified as suitable for VFC review, with a further four discussed in detail. A reduction of face to face appointments of up to 50% was reported with greater compliance to BOAST guidelines (46.4%) and cost saving (up to £212,000). CONCLUSIONS: This systematic review demonstrates that the VFC model can help deliver a safe, more cost-effective, and more efficient arm of the trauma service to patients.Cite this article: Bone Joint Open 2020;1-11:683-690.

The Assessment and Management of the Arthritic Knee: An Update.

Musculoskeletal disorders represent a significant primary care burden. Presentations pertaining to the painful knee are associated with a wide array of differentials; however, among these, osteoarthritis (OA) is the most common one in patients older than 45 years. We have found that a significant number of onward secondary care referrals are misdirected. Therefore, there is a need for a comprehensive assessment and workup to ensure holistic patient care and timely input from specialist services. In this article, we highlight an approach to the management of the arthritic knee.

Standardised Warfarin Reversal Expedites Time to Theatre for Fractured Neck of Femur Surgery and Improves Mortality Rates: A Matched Cohort Study.

BACKGROUND: This study aims to evaluate outcomes for warfarinised hip fracture patients and compare them with a matched nonwarfarinised group, before and after the introduction of national hip fracture guidelines in the United Kingdom. METHODS: A retrospective cohort study of 1743 hip fracture patients was undertaken. All patients admitted taking warfarin were identified. These patients were then matched to nonwarfarinised patients using nearest neighbour propensity score matching, accounting for age, sex, hip fracture type, and Nottingham Hip Fracture Score. A pre-guideline group (no standardised warfarin reversal regimen) and a post-guideline group (standardised regimen) were identified. Outcomes assessed included time to INR less than 1.7, time to theatre, length of stay, and 30-day and 1-year mortality. RESULTS: Forty-six warfarinised hip fracture patients were admitted in the pre-guideline group (mean age 80.5, F:M 3:1) and 48 in the post-guideline group (mean age 81.2 years, F:M 3:1). Post-guideline patients were reversed to a safe operative INR level within 18 hours of admission, decreasing the time to first dose vitamin K (p<0.001). 70% of warfarinised patients were operated upon within 36 hours, compared to 19.6% with no regimen (p<0.05). After anticoagulation reversal protocol, thirty-day mortality decreased from 15.2% to 8.3% and 1-year mortality from 43.5% to 33% for warfarinised patients, which is comparable to nonwarfarinised matched patients. There was no significant change in the length of stay pre- and post-guideline for both groups of patients. CONCLUSIONS: Proactive anticoagulant management and expedient surgery reduces morbidity and mortality when managing this surgically challenging subset of hip fracture patients.

Apert syndrome: Be aware of the 'dodgy' hip!

Apert syndrome is a rare congenital disorder characterised by craniosynostosis, midface hypoplasia and syndactyly of hands and feet. Here we present a case of a 44-year-old woman, with a genetic diagnosis of Apert syndrome from birth, who presented with symptomatic left-sided hip osteoarthritis secondary to femoral abnormalities. She proceeded to have a total hip replacement. This case report describes the rare occurrence to identify a possible association between Apert syndrome and hip abnormalities.

10-year results of the Birmingham Hip Resurfacing: a non-designer case series.

INTRODUCTION: Recent controversies surrounding metal-on-metal (MoM) hip resurfacing has led to a substantial decline in its use. Despite this, there is good evidence to support the use of specific implants in select patients. PATIENTS AND METHODS: A retrospective analysis of Birmingham Hip Resurfacing (BHR) patients with a minimum of 10 years follow-up was performed. Functional scoring was performed with the Oxford Hip Score (OHS) and failure was defined as revision for any cause. 111 patients underwent 121 BHR procedures. All patients had a minimum follow-up of 10 years. 70 patients (63%) were male. Mean patient age at surgery was 52.5 years (male 53.9 years, female 48.8 years). RESULTS: Overall survival at 10 years was 91% (97% male, 80% female). There was a statistically significant improvement in OHS postoperatively which remains at 10-year follow-up (p = <0.05). There was no significant difference in scores between the male and female groups. Revisions were most often in patients with smaller component sizes but this was not found to be statistically significant. CONCLUSIONS: Our results reflect that of the wider literature in that good outcomes can be obtained with this implant in a select group of patients and results are comparable to that of conventional hip arthroplasty in patients of a similar age.

A Conservatively Managed Anatomical Variant of the Flexor Digitorum Superficialis Muscle in the Hand.

Anomalous flexor digitorum superficialis muscles in the hand are an uncommon phenomenon, and therefore present challenges in diagnosis and management. We report a case of a 16-year-old girl presenting with a painful, slowly enlarging palmar swelling. The swelling was investigated with ultrasound and magnetic resonance imaging, and was found to be an anomalous muscle belly of the flexor digitorum superficialis muscle. After careful consideration, multidisciplinary discussion, and thorough imaging, the patient was treated successfully without surgical exploration or excision, in comparison to previously reported cases. The patient was pain free and had no concerns at 8-month follow-up, demonstrating the value of conservative management in these cases.

Preoperative warfarin reversal for early hip fracture surgery.

PURPOSE: To evaluate our hospital protocol of low-dose vitamin K titration for preoperative warfarin reversal for early hip fracture surgery. METHODS: Records of 16 men and 33 women aged 63 to 93 (mean, 81) years who were taking warfarin for atrial fibrillation (n=40), venous thromboembolism (n=9), cerebrovascular accident (n=3), and prosthetic heart valve (n=3) and underwent surgery for hip fractures were reviewed. The 3 patients with a prosthetic heart valve were deemed high risk for thromboembolism and the remainder low-risk. The international normalised ratio (INR) of patients was checked on admission and 6 hours after administration of vitamin K; an INR of <1.7 was considered safe for surgery. RESULTS: No patient developed venous thromboembolism within one year. The 30-day and one-year mortality was 8.2% and 32.6%, respectively. For the 46 low-risk patients, the mean INR on admission was 2.6 (range, 1.1-4.6) and decreased to <1.7 after a mean of 2.2 (range, 0-4) administrations of 2 mg of vitamin K. Their INR was <1.7 within 18 hours (mean, 14 hours). 78% of patients underwent surgery within 36 hours. In the 22% of patients who did not undergo surgery within 36 hours, the delay was due to insufficient operative time or the patient being medically unfit for surgery. The 3 high-risk patients underwent bridging therapy of low-molecular-weight heparin and received no vitamin K; their mean INR on admission was 3.2 (range, 3.1-3.3) and the mean time to surgery was 5.3 (range, 3-8) days. Two low-risk patients and one high-risk patient died within 5 days of surgery. CONCLUSION: The low-dose intravenous vitamin K protocol is safe and effective in reversing warfarin within 18 hours. Hip fracture surgery within 36 to 48 hours of admission improves morbidity and mortality.

Nintendo Wii related Achilles tendon rupture: first reported case and literature review of motion sensing video game injuries.

Achilles tendon ruptures tend to occur more commonly in healthy men between the ages of 30 and 50 years who have had no previous injury or problem reported in the affected leg. The injury is usually due to sudden forced plantar flexion of the foot, unexpected dorsiflexion of the foot and violent dorsiflexion of a plantar flexed foot, all of which occur during high impact activities. We present the first reported case of interactive activity with Nintendo Wii games that have resulted in Achilles tendon rupture in a 46-year-old man. There have been no previous reports of Achilles tendon rupture with Nintendo Wii usage; it is a relatively uncommon mode of injury and is rare in terms of epidemiology of motion sensing video game injuries.

Disassociation at the head-trunnion interface: an unseen complication of modular hip hemiarthroplasty.

A woman in her mid-90s underwent a left uncemented bipolar hemiarthroplasty for an intracapsular femoral neck fracture. Postoperative radiographs at 48h showed a disassociation of the left femoral prosthesis at the head-trunnion interface, with the bipolar head remaining in the acetabulum. There was no preceding trauma and the patient had mobilised postoperatively. The hip was revised to a monopolar head, and the patient's hip was protected postoperatively in a brace limiting flexion and external rotation. At 30 days following revision she was mobilising pain-free with a stable hip. Disassociation at the head-trunnion interface has never been reported in hip hemiarthroplasty, and is only described in relation to primary or revision total hip replacements (THR) following dislocation or trauma to the THR. This demonstrates a potential complication of modular prostheses for trauma.

An exceptionally large giant lipoma of the hand.

Lipomas are benign tumours that consist of mature adipocytes. They are the commonest soft tissue tumours, most frequently seen in the trunk and proximal extremities. Lesions in the hand are uncommon, and giant lipomas of the hand, defined as greater than 5 cm in size, are particularly rare. We present a case of an exceptionally large giant lipoma of the hand, presenting as an extremely large inconvenient swelling of the palm in a 67-year-old woman. The diagnosis of lipoma was suggested via ultrasonography, and confirmed via MRI and histology. The lesion was successfully excised with no postoperative neurovascular deficit. The excised lesion measured 8×6×3 cm, one of the largest giant lipomas of the hand reported to date. When patients present with large lesions such as these a malignant cause must always be considered, and appropriate early imaging is essential when assessing these patients.

Internal iliac aneurysm presenting with lower back pain, sciatica and foot drop.

Internal iliac aneurysms are usually silent and are identified as an incidental finding on a radiological investigation for an unrelated condition, unless catastrophic bleeding occurs. We present the first case of a middle-aged man with a large internal iliac aneurysm presenting with a foot drop and sciatic nerve pain. The endovascular management is discussed.

'Memorable patient deaths': reactions of hospital doctors and their need for support.

OBJECTIVES: To investigate the reactions experienced by hospital doctors following a recent memorable patient death, defined as a patient death that had occurred in the previous few months that the doctor recollected for any particular reason, the coping strategies employed to deal with these reactions, the impact of training, and the need for support in future situations. METHODS: We carried out a descriptive survey in 2 teaching hospitals and 1 district general hospital in West Yorkshire, UK. Subjects comprised 188 hospital doctors of all grades (from pre-registration house officer to consultant) who were attending 12 educational lunchtime meetings. Main outcome measures included the associations between the intensity of emotional and physical reactions measured using a categorical rating scale, and exposure to previous training, gender, seniority and medical specialty. RESULTS: Reactions of moderate to severe intensity to a patient death were experienced by 5.0-17.5% of doctors, regardless of gender, seniority or medical specialty. Perceived need for both training and increased support from team members was significantly associated with more intense reactions. Common coping strategies included talking, spending time alone and exercise. There was no relationship between respondents' exposure to previous training and the intensity of emotional or physical responses. CONCLUSIONS: Many doctors perceive that they deal with death well. In a minority of doctors, more supportive approaches are necessary that may include both proactive and reactive measures. Examples include raising awareness of support services and establishing formal training programmes, and increasing awareness among senior clinicians of the need to support some team members after a patient's death, which may include ensuring that timely access to a counsellor is provided.