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.

Current practice of BHS members in the treatment of osteonecrosis of the femoral head in adults.

INTRODUCTION: The management of osteonecrosis (ON) of the femoral head remains controversial. It is unclear the extent to which non-arthroplasty procedures are used and there has been no previous report of the trends in operative management of ON in the UK. Our objective is to report current trends in management of ON of the femoral head amongst specialist hip surgeons in the UK. METHODS: A single-stage internet-based survey was e-mailed to 352 eligible members of the British Hip Society (BHS). This consisted of 10 question stems including 16 hypothetical clinical scenarios with imaging. RESULTS: 115 active Consultant members of the BHS completed the survey. For symptomatic pre-collapse ON we found core decompression (CD) was the most common operative intervention and for post-collapse ON we found that total hip arthroplasty (THA) was the most common operative intervention. We found no difference in the rate of operative intervention between 24 and 48-year-old patients at any stage of ON but joint preserving procedures were more often selected for the younger patient and arthroplasty for the older patient. Surgeons were more likely to offer arthroplasty to a 48-year-old patient at an earlier stage of disease. CONCLUSIONS: Our respondents would offer different operative interventions dependent on stage of ON and patient age. Core decompression (CD) and arthroplasty were common but variation in treatment options offered suggests a lack of consensus amongst UK hip surgeons. We suggest that further research such as a prospective RCT is needed to gain consensus on management of this condition.

How to salvage a salvage endoprosthesis.

Custom-made endoprostheses can be linked to existing well-fixed implants in the treatment of complex periprosthetic femoral fractures. By adopting this salvage approach, secure implants can be retained in favour of patients undergoing more tissue disruptive procedures such as total femoral replacements. In this piece, we present a unique case illustrating a salvage strategy for treating a failed cement-linked salvage endoprosthesis, a complex scenario which to our knowledge has never before been reported.

Injuries associated with recreational horse riding and changes over the last 20 years: a review.

OBJECTIVE: To assess the incidence and distribution of recreational equestrian injuries seen in the Kent and Sussex region and review the available literature on this subject. DESIGN: This is a retrospective case series with historical controls. SETTING: Kent and Sussex region, England. MAIN OUTCOME MEASUREMENT: Injuries related to horses in the recreational setting. METHODS: Subjects were selected from our acute injury database. Notes of all patients presenting with horse riding-related injuries between January and December 2010 were reviewed. Skeletal injuries were confirmed using our Picture Archiving and Communications Systems (PACS) system. Data were tabulated and grouped using Microsoft Excel software. Statistics were calculated using Graph Pad software. RESULTS: During the study period, 155 patients presented with a total of 199 injuries related to horses, accounting for 0.3% of all presentations; 69% were soft tissue injuries. The most commonly affected areas were the extremities (77 patients, 49.7%) followed by injuries to the head (38 patients, 24.5%) and trunk (36 patients, 23.2%). Seventeen patients (11%) were admitted. Patients presenting with head injuries suffered significantly more injuries compared to other groups (1.65 compared to 1.4 injuries, p < 0.0002). CONCLUSION: A larger number of persons were riding for a longer period of the year compared to previous studies in the United Kingdom. There was also a shift in the patterns of injury seen in this population over the last two to three decades.

Comparative endurance testing of the Biomet Matthews Nail and the dynamic compression screw, in simulated condylar and supracondylar femoral fractures.

BACKGROUND: The dynamic compression screw is a plate and screws implant used to treat fractures of the distal femur. The Biomet Matthews Nail is a new retrograde intramedullary nail designed as an alternative surgical option to treat these fractures. The objective of this study was to assess the comparative endurance of both devices. METHOD: The dynamic compression screw (DCS) and Biomet Matthews Nail (BMN) were implanted into composite femurs, which were subsequently cyclically loaded using a materials testing machine. Simulated fractures were applied to each femur prior to the application of load. Either a Y type fracture or a transverse osteotomy was prepared on each composite femur using a jig to enable consistent positioning of cuts. RESULTS: The Biomet Matthews Nail demonstrated a greater endurance limit load over the dynamic compression screw in both fracture configurations. CONCLUSION: The distal locking screws pass through the Biomet Matthews Nail in a unique "cruciate" orientation. This allows for greater purchase in the bone of the femoral condyle and potentially improves the stability of the fracture fixation. As these fractures are usually in weak osteoporotic bone, the Biomet Matthews Nail represents a favourable surgical option in these patients.