The use of radiomic analysis of magnetic resonance imaging findings in predicting features of early osteoarthritis of the knee-a systematic review and meta-analysis.

The primary aim of this study was to systematically review current literature evaluating the use of radiomics in establishing the role of magnetic resonance imaging (MRI) findings in native knees in predicting features of osteoarthritis (OA). A systematic review was performed with respect to PRISMA guidelines in search of studies reporting radiomic analysis of magnetic resonance imaging (MRI) to analyse patients with native knee OA. Sensitivity and specificity of radiomic analyses were included for meta-analysis. Following our initial literature search of 1271 studies, only 5 studies met our inclusion criteria. This included 1730 patients (71.5% females) with a mean age of 55.4 ± 15.6 years (range 24-66). The mean RQS of included studies was 16.6 (11-21). Meta-analysis demonstrated the pooled sensitivity and specificity for MRI in predicting features of OA in patients with native knees were 0.74 (95% CI 0.71, 0.78) and 0.85 (95% CI 0.83, 0.87), respectively. The results of this systematic review suggest that the high sensitivities and specificity of MRI-based radiomics may represent potential biomarker in the early identification and classification of native knee OA. Such analysis may inform surgeons to facilitate earlier non-operative management of knee OA in the select pre-symptomatic patients, prior to clinical or radiological evidence of degenerative change.

The utility of cemented femoral stems in modern THA: a 10-year comparative analysis of the Charnley and Exeter stems.

BACKGROUND: Total hip replacement (THR) is one of the most common surgical procedures performed worldwide. The controversy surrounding the relative merits of a cemented composite beam or cemented taper-slip stem in total hip replacement continues. Our aims primarily were to assess the 10-year outcomes of cemented stems using Charnley and Exeter prostheses with regional registry data and secondarily to assess the main predictors of revision. METHODS: We prospectively collected registry data for procedures performed between January 2005 and June 2008. Only cemented Charnley and Exeter stems were included. Patients were prospectively reviewed at 6 months, 2, 5 and 10 years. The primary outcome measure was a 10-year all-cause revision. Secondary outcomes included 're-revision', 'mortality' and functional 'Western Ontario and McMaster Universities Osteoarthritis Index' (WOMAC) scores. RESULTS: We recorded a total of 1351 cases in the cohort, 395 Exeter and 956 Charnley stems. The overall all-cause revision rate at 10 years was 1.6%. The revision rate for Charnley stem was 1.4% and 2.3% revision rate for all Exeter stems with no significant difference noted between the two cohorts (p = 0.24). The overall time to revision was 38.3 months. WOMAC scores at 10 years were found to be insignificantly higher for Charnley stems (mean 23.8, σ = 20.11) compared to Exeter stems (mean 19.78, σ = 20.72) (p = 0.1). CONCLUSION: There is no significant difference between cemented Charnley and Exeter stems; they both perform well above the international average. The decline in the use of cemented THA is not fully supported by this regional registry data.

The Irish National Orthopaedic Register Under Cyberattack: What Happened, and What Were the Consequences?

BACKGROUND: On May 14, 2021, a criminal cyberattack was launched against the Irish public healthcare system, the Health Service Executive, resulting in a complete shutdown of all national healthcare computer systems, including the Irish National Orthopaedic Register (INOR). Cyberattacks of this kind occur sporadically, and postevent analyses can inform future preparedness efforts, but few such analyses have been published. QUESTION/PURPOSE: What was the impact of the cyberattack in terms of (1) registry downtime, (2) harms to patients, and (3) costs to the INOR for data contingency and reconciliation? METHODS: All nine hospitals using the INOR were included for data collection. Since establishment in 2014, the INOR has been rolled out to all eight public elective hospitals, capturing all hip and knee arthroplasty procedures. One private hospital was also captured, with plans to expand the private sector coverage. Individual institutional records and central INOR records were queried with respect to downtime, potential harms to patients (including intraoperative complications because of a lack of data on existing implanted components and complications directly attributed to delayed or canceled procedures), and costs related to additional person-hours addressing data reconciliation. Objective data directly related to the uncontrolled INOR downtime were collected, including duration of downtime, contingency methods employed, quality of contingency data collected, adverse patient events, methods of data salvage and reconciliation, and the cost of data contingency and reconciliation measures. Costs were estimated by the additional person-hours of work completed, multiplied by the hourly rate of that employee. Employees at each of the nine hospitals were asked to provide their additional person-hours of work performed because of the attack. These hours were corroborated by observing the time taken at each unit to reconcile data for single cases multiplied by the number of cases at that unit. Employees included nurses, clinical nurse specialists, and doctors of various grades. Person-hour rates were calculated using the Health Service Executive's published salary scales. RESULTS: The INOR suffered a median downtime of 134 days (range 119 to 272 days) across nine sites. No serious adverse patient events were identified. The immediate implementation of a paperwork fallback method for the INOR successfully resulted in 100% case capture during the downtime. However, 2850 additional person-hours were required for data reconciliation at an estimated cost of USD 181,000 to USD 216,000. More subjectively, as reported by interviews with INOR leads at each hospital, the cyberattack negatively impacted operating room efficiency with delays between procedures because of additional paperwork data collection, disrupted patient flow for paperwork data collection on the ward level and in the outpatient clinics, and disrupted resource allocations and staff capabilities because of additional paperwork requirements during the contingency period. CONCLUSION: Disruptions to data collection and data accessibility after this cyberattack were successfully countered by a contingency plan; however, substantial financial costs and additional resources were required for data conservation and reconciliation. CLINICAL RELEVANCE: In addition to robust preventative security measures, national registers and other healthcare systems should have secondary data backup facilities and reliable fallback procedures prepared for such events.

Obesity trends over 10 years in primary hip and knee arthroplasty-a study of 12,000 patients.

OBJECTIVES/AIMS: Obesity and its increasing prevalence are global public health concerns. Following joint replacement, there is evidence to support that obese patients are more likely to suffer complications. We examined 10-year trends in BMI of the primary total hip and total knee replacement cohorts in our institution to discern whether the BMI of these patients has changed over time. METHODS: We examined BMI data of patients who underwent primary hip and knee arthroplasty from our institutional database from January 1, 2010 to December 31, 2019 (n = 12,169). We analysed trends in BMI over this period with respect to (i) surgical procedure, (ii) gender, and (iii) age categories. RESULTS: The overall number of surgical procedures increased over the study period which meant more obese patients underwent surgery over time. Average BMI did not change significantly over time; however, there was a statistically significant increase in BMI in females aged < 45 in both arthroplasty groups. CONCLUSION: The average BMI of patients undergoing primary hip and knee arthroplasty in our high-volume tertiary orthopaedic centre has remained relatively unchanged over the past 10 years; however, our local service is caring for a greater number of overweight/obese patients due to the increase in overall volume. This will have significant implications on health care expenditure and infrastructure going forward which further emphasises the importance of ongoing national obesity prevention strategies. The increase in BMI seen in females aged < 45 may mark an impending era of obese younger patients with end-stage osteoarthritis.

Third and fourth generation ceramic-on-ceramic total hip arthroplasty at a minimum of ten years.

Background: Ceramic on Ceramic bearings in Total Hip Arthroplasty (THA) afford a low friction coefficient, low wear rates and extreme hardness. Significant complications include hip squeak, ceramic fracture and poor polyethylene performance in revision procedures due to imbedding of abrasive microscopic ceramic fragments. We report on the results of this bearing at a minimum of 10 years. Methods: A single-centre retrospective review of 449 THAs was performed. Primary outcome measures included aseptic revision and all-cause revision rates at a minimum of 10 years post operatively. Evaluation of functionality was performed with WOMAC and SF-36 scores which were performed pre-operatively and at intervals of 6 months, one year, 2 years, 5 years and 10 years post operatively. Results: There was a 6.2% (n = 28) all-cause and 5.3% (n = 24) aseptic revision rate for ceramic on ceramic total hip arthroplasty at minimum of 10 years with a mean time to revision 4.8 years (range 2 months-11.6 years). Notably, there were 2 revisions for ceramic head fracture, one for ceramic liner fracture, 3 for aseptic loosening and 3 revisions for squeaking. Pain of unknown origin was the most common reason for revision. There was an improvement in postoperative WOMAC scores from a mean of 59.8 (range 15-95) pre-operatively to a mean of 15.6 (range 0-78) at 10 years. Conclusion: This study showed good functional outcomes but high revision rates for CoC THA at a minimum of 10 years. Our rates of ceramic fracture were consistent with other studies.

Can Bar Code Scanning Improve Data Capture in a National Register? Findings from the Irish National Orthopaedic Register.

BACKGROUND: The Irish National Orthopaedic Register (INOR) provides a national mechanism for managing data on THA and TKA in Ireland, including a detailed implant record populated by intraoperative implant bar code scanning. It is critically important that implant details are recorded accurately for longitudinal outcome studies, implant recalls, and revision surgery planning. Before INOR's 2014 launch, Irish hospitals maintained separate, local institutional arthroplasty databases. These individual databases typically took the form of hardcopy operating room (OR) logbooks with handwritten patient details alongside the descriptive stickers from the implant packaging and/or individual institution electronic records using manual electronic implant data input. With the introduction of the INOR, a single, unifying national database was established with the ability to instead collect implant data using bar code scanning at time of implant unpackaging in the OR. We observed that bar code data entry represented a novel and potentially substantial change to implant recording methods at our institution and so sought to examine the potential effect on implant data quality. QUESTIONS/PURPOSES: We compared the new bar code scanning method of implant data collection used by the INOR to the previously employed recording methods at our institution (in our case, the previous methods included both an electronic operation note database [Bluespier software] and a duplicate hardcopy OR logbook) and asked (1) Does bar code scanning improve the completeness of implant records? (2) Does bar code scanning improve the accuracy of implant records? METHODS: Although the INOR was launched in 2014, our institution went live with it in 2019. To avoid any potential recording issues that may have occurred during the 2019 introduction of the novel system, a clear period before the introduction of INOR was selected at our institution to represent an era of manual data input to Bluespier software: July 2018. Although we initially aimed for 2 months of data from July 1, 2018, to August 31, 2018 (n = 247), we decided to proceed to 250 consecutive, primary THAs or TKAs for clarity of results. No procedure meeting these criteria was excluded. A second recent period, January 2021, was identified to represent an era of bar code data input; 250 consecutive, primary THAs or TKAs were also included from this date (to February 15, 2021). No case meeting these criteria was excluded. A total of 4244 implant parameters from these 500 primary THAs or TKAs were manually cross-referenced for missing or incorrect data. Eleven THA and six TKA parameters were chosen for comparison, including implant names and component sizes. For each case, either the 2018 Bluespier electronic record or the 2021 INOR electronic record was manually interrogated, and implant details were recorded by two authors before they were compared against the duplicate record for every case (the reference-standard OR logbook containing the corresponding implant product stickers) for both completeness and accuracy. Completeness was defined binarily as the implant parameter being either present or absent; we did likewise for accuracy, either that parameter was correct or incorrect. The OR logbooks were chosen as the reference standard because we felt the risk of product stickers containing errors (inaccuracies) was negligible, and in our collective experience, missing stickers (incompleteness) has not been encountered. Logbook case completeness was also confirmed by comparison to our inpatient management system. RESULTS: With the introduction of the automated bar code data entry in the INOR, the proportion of missing data declined from 7% (135 of 2051) to 0% (0 of 2193), and the proportion of incorrectly recorded implant parameters declined from 2% (45 of 2051) to 0% (0 of 2193). The proportion of procedures with entirely accurate implant records rose from 53% (133 of 250) to 100% (250 of 250). CONCLUSION: The completeness and accuracy of implant data capture was improved after the introduction of a contemporary electronic national arthroplasty registry that utilizes bar code data entry. CLINICAL RELEVANCE: Based on the results of this study, other local and national registers may consider bar code data entry in the OR to achieve excellent implant data quality. Future studies may examine implant data quality at a national level to validate the bar code-populated data of the INOR.

Assessment of previous fracture and anti-osteoporotic medication prescription in hip fracture patients.

INTRODUCTION: Hip fracture prevention is an essential component in elderly patient care. History of prior fracture is a significant risk factor for subsequent hip fracture. There are variable rates of treatment for these groups of patients. The aims of this study were to make an assessment of how many hip fracture patients over a 1 year period had a previous fracture and to assess whether or not these patients were on anti-osteoporotic medication. METHODS: Assessment on whether or not patients had a prior fracture using the national radiology imaging system checking radiology reports for all previous imaging performed. Checking patients bone health status using the hip fracture database for our hospital. RESULTS: There were 225 hip fractures in 221 patients over a 1-year period. About 42.6% of females and 35.9% of males had a history of previous fracture. Vertebral fractures were the most common type of fracture. We found 7% of patients had a contralateral hip fracture. There were 81% of patients with prior fracture, and 71% of those without prior fracture were on anti-osteoporotic medication. DISCUSSION: Vertebral fractures were the most common preceding fracture in hip fracture patients. There were many patients with a history of fragility fractures that were not on preventative medication. Overall there were good prescription rates of anti-osteoporotic medication. There were significantly higher rates of prescription amongst females compared with males.

A multi-site review of second hip fractures across 6 Dublin teaching hospitals.

INTRODUCTION: Fragility hip fractures are common and costly. Secondary fracture prevention is a treatment goal following hip fracture; however, the number of those that proceed to fracture their contralateral hip in Ireland is unknown. There are plans to introduce a Fracture Liaison Service Database in Ireland which will aim to prevent secondary fractures. To establish a baseline figure for secondary hip fractures, the injury radiographs of 1284 patients from 6 teaching hospitals over a 1-year period were reviewed. METHODS: Irish Hip Fracture Datasheets and corresponding injury radiographs were reviewed locally for all hip fractures within each respective teaching hospital for a 1-year period (2019). RESULTS: A total of 8.7% of all fragility hip fractures across the 6 hospitals were secondary hip fractures (range 4.9-11.5%). 46% occurred within years 1 to 3 following index hip fracture. Forty-eight per cent of patients were started on bone protection medications following their second hip fracture. DISCUSSION/CONCLUSION: Approximately 1 in 11 hip fractures treated across the 6 teaching hospitals assessed in 2019 was a patient's second hip fracture. We advocate for the widespread availability of Fracture Liaison Services to patients throughout Ireland to assist secondary fracture prevention.

Outcomes of the Exeter V40 cemented femoral stem at a minimum of ten years in a non-designer centre.

AIMS: The Exeter V40 cemented femoral stem was first introduced in 2000. The largest single-centre analysis of this implant to date was published in 2018 by Westerman et al. Excellent results were reported at a minimum of ten years for the first 540 cases performed at the designer centre in the Exeter NHS Trust, with stem survivorship of 96.8%. The aim of this current study is to report long-term outcomes and survivorship for the Exeter V40 stem in a non-designer centre. METHODS: All patients undergoing primary total hip arthroplasty using the Exeter V40 femoral stem between 1 January 2005 and 31 January 2010 were eligible for inclusion. Data were collected prospectively, with routine follow-up at six to 12 months, two years, five years, and ten years. Functional outcomes were assessed using Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores. Outcome measures included data on all components in situ beyond ten years, death occurring within ten years with components in situ, and all-cause revision surgery. RESULTS: A total of 829 stems in 745 patients were included in the dataset; 155 patients (20.8%) died within ten years, and of the remaining 664 stems, 648 stems (97.6%) remained in situ beyond ten years. For the 21 patients (2.5%) undergoing revision surgery, 16 femoral stems (1.9%) were revised and 18 acetabular components (2.2%) were revised. Indications for revision in order of decreasing frequency were infection (n = 6), pain (n = 6), aseptic component loosening (n = 3), periprosthetic fracture (n = 3), recurrent dislocation (n = 2), and noise production (ceramic-on-ceramic squeak) (n = 1). One patient was revised for aseptic stem loosening. The mean preoperative WOMAC score was 61 (SD 15.9) with a mean postoperative score of 20.4 (SD 19.3) (n = 732; 88.3%). CONCLUSION: The Exeter V40 cemented femoral stem demonstrates excellent functional outcomes and survival when used in a high volume non-designer centre. Outcomes are comparable to those of its serially validated predecessor, the Exeter Universal stem.Cite this article: Bone Jt Open 2020;1-12:743-748.

Analysing the variation in volume and nature of trauma presentations during COVID-19 lockdown in Ireland.

AIMS: Europe has found itself at the epicentre of the COVID-19 pandemic. Naturally, this has placed added strain onto healthcare systems internationally. It was feared that the impact of the COVID-19 pandemic could overrun the Irish healthcare system. As such, the Irish government opted to introduce a national lockdown on the 27 March 2020 in an attempt to stem the flow of admissions to hospitals. Similar lockdowns in the UK and New Zealand have resulted in reduced emergency department presentations and trauma admissions. The aim of this study is to assess the effect of the national lockdown on trauma presentations to a model-3 hospital in Dublin, Ireland. METHODS: A retrospective study was conducted. All emergency department presentations between 27 March 2019 to 27 April 2020 and 27 March 2020 to 27 April 2020 were cross-referenced against the National Integrated Medical Imaging System-Picture Archiving Communication System (NIMIS-PACS) radiology system to identify those with radiologically proven skeletal trauma. These patients were grouped according to sex, age, discharge outcome, mechanism of injury, and injury location. RESULTS: A 21% decrease in radiologically proven trauma was observed on comparison with the same time-period last year. Additionally, a 40% reduction in trauma admissions was observed during the COVID-19 lockdown. A 60% reduction in sports-related injuries and road traffic accident-related injuries was noted during the national lockdown. However, a 17% increase was observed in patients sustaining trauma because of domestic accidents. CONCLUSION: Variation was observed in both the volume and nature of trauma presentations during the COVID-19 lockdown. As would be expected, a reduction was seen in the number of injuries resulting from outdoor activities. Interestingly, increased rates of domestic injuries were seen during this period which could represent an unintended consequence of the prolonged period of lockdown.Cite this article: Bone Joint Open 2020;1-6:261-266.

Assessing the Attitudes, Awareness, and Behavioral Alterations of Patients Awaiting Total Hip Arthroplasty During the COVID-19 Crisis.

BACKGROUND: COVID-19 has placed a huge burden on healthcare systems which has led to widespread cancellation elective surgical care. Ireland is recovering from the first wave of COVID-19 and as such the expeditious return of elective surgical care is important. This is the first study to examine the attitudes of patients to undergoing total joint arthroplasty during the COVID-19 crisis. METHODS: A prospective qualitative study was undertaken in our institution during the week 13/05/2020-20/05/2020. 65 patients completed a questionnaire assessing attitudes, awareness, and behavioral changes associated with COVID-19, a Charlson Comorbidity Index, modified-Harris Hip Score, and a Short Form-12 score. RESULTS: 86% of patients felt that they were at little to no risk of COVID-19 infection. The majority of patients were happy to proceed with surgery at the current level of COVID-19 related threat (86%). Patients with higher mHHS were more likely to postpone their operation than those with lower mHHS scores. Our cohort had low patient reported outcome measures in both mHHS and SF-12, indicating the significant burden of hip osteoarthritis on both physical and mental health. CONCLUSION: Patients reported a significant disease-related impairment of physical function and subsequent deterioration in mental health as a result of hip osteoarthritis. Patients with worse hip function, as measured by the mHHS are more willing to proceed with surgery than those with superior hip function. This offers a potential mechanism by which to triage patients once elective surgical pathways reopen in the coming months.

Current concepts and outcomes in cemented femoral stem design and cementation techniques: the argument for a new classification system.

Cemented implant fixation design principles have evolved since the 1950s, and various femoral stem designs are currently in use to provide a stable construct between the implant-cement and cement-bone interfaces.Cemented stems have classically been classified into two broad categories: taper slip or force closed, and composite beams or shaped closed designs. While these simplifications are acceptable general categories, there are other important surgical details that need to be taken into consideration such as different broaching techniques, cementing techniques and mantle thickness.With the evolution of cemented implants, the introduction of newer implants which have hybrid properties, and the use of different broaching techniques, the classification of a very heterogenous group of implants into simple binary categories becomes increasingly difficult. A more comprehensive classification system would aid in comparison of results and better understanding of the implants' biomechanics.We review these differing stem designs, their respective cementing techniques and geometries. We then propose a simple four-part classification system and summarize the long-term outcomes and international registry data for each respective type of cemented prosthesis. Cite this article: EFORT Open Rev 2020;5:241-252. DOI: 10.1302/2058-5241.5.190034.

Bypass: an integrated hip fracture care pathway.

BACKGROUND: The incidence of hip fractures is expected to increase over the coming years, placing a greater burden on limited resources. A high volume of patients is brought to hospitals that do not have the resources necessary to provide definitive care. Optimal care involves a coordinated and integrated system of trauma care. The hip fracture care pathway introduced between a referring peripheral hospital and our institution represents a coordinated multidisciplinary approach to patient care. AIMS: To describe and report on the outcomes over an 18-month period of the integrated hip fracture care pathway between referring peripheral hospitals and our institution. METHODS: A retrospective analysis of the prospectively maintained hip fracture database over an 18-month period. RESULTS: Between March 2017 and September 2018, 86 consecutive patients were referred to our institution through a new referral pathway. Of these, 69 patients came from the Emergency Department of the referring hospital and 17 arrived via bypass. All 86 patients were managed on a specialist orthopaedic ward. The average length of stay was 4.28 days, with maximum of 13 and minimum of 2 days. Over 84% of patients underwent definitive treatment within 48 h of a diagnosed hip fracture. DISCUSSION: The fragmented approach to the management of trauma patients both in a pre-hospital and hospital care setting is a cause for concern. Our integrated hip fracture referral pathway, incorporating bypass of the referring hospital, represents a multidisciplinary care pathway for the management of patients with fractured neck of femur and can have potential benefits including improved patient outcomes, allowing the optimal allocation of resources and providing training opportunities.

Connolly Hospital Trauma Assessment Clinic (TAC): a virtual solution to patient flow.

BACKGROUND: Trauma Assessment Clinics (TAC) were pioneered by the Glasgow Royal Infirmary Group. Patients deemed for non-operative management are referred to the TAC for review by an orthopaedic consultant with multidisciplinary team (MDT) support. Connolly Hospital launched a TAC on 11 September 2018. AIMS: The goal of this study was to evaluate the effect the introduction of this initiative had on patient flow in our institution. METHODS: We performed a retrospective review of the Connolly Hospital TAC for the 6-month period since its introduction. We evaluated patient demographics, injuries and outcomes. Furthermore, we retrospectively reviewed the fracture and elective clinic attendances pre- and post-TAC introduction. RESULTS: Over the first 6 months of this initiative, there were 36 trauma assessment clinics. Two hundred forty-seven patients were reviewed with an average age of 42.3 years. 42.9% (N = 106) was reviewed directly by the physiotherapy department. 31.6% (N = 78) was scheduled directly for fracture clinic follow-up from the TAC. 8.2% (N = 45) was discharged directly to their GP from TAC. A review of fracture clinic attendances for the corresponding time period the previous year (from September 2017), highlighted a 22% decrease in new fracture clinic appointments. CONCLUSIONS: Following the introduction of the TAC, we noted a marked reduction in fracture clinic attendances. Our outcomes were consistent with results from other units. We established two injection clinics as a direct result of the time saved from the TAC. It has proven to be of benefit to both the trauma and elective patients in our institution.

The effect of indirect admission via hospital transfer on hip fracture patients in Ireland.

BACKGROUND AND AIMS: Current best practice states that hip fracture patients should undergo surgery within 48 hours to minimise perioperative complications. There are 10 emergency departments (EDs) in Ireland that receive hip fracture patients without a trauma and orthopaedic surgery unit on site. Idle periods and duplicated preoperative investigations can lead to a prolonged time to surgery. The aim of this study was to identify the effect of admission route on the time to surgery, length of stay and pressure ulcer development in patients who sustain a hip fracture in Ireland. METHODS: A retrospective cohort study was performed, using 2013 and 2014 data from the Irish Hip Fracture Database. Age, gender and ASA grade were identified as confounders and adjusted for accordingly. RESULTS: Of the 3893 hip fractures identified, indirect admissions via hospital transfer occurred in 8.6% of cases. Surgery was performed within 48 h in 72.0% of indirect admission and 73.7% of direct admission cases (p = 0.502). The length of stay was significantly prolonged for patients admitted via hospital transfer (25.6 compared to 19.6 days, p < 0.001). CONCLUSION: Delayed discharges post hip fracture have been shown to expose patients to increased perioperative morbidity and mortality rates, as well as reduced rehabilitation potential and less chance of returning home on discharge. This has significant cost implications for the health service and justifies the introduction of hospital bypass protocols for patients with hip fractures.

Failed osteosynthesis of cemented B1 periprosthetic fractures.

BACKGROUND: Periprosthetic fractures about the hip are increasingly common. The literature estimates a failure rate of approximately 10% in Vancouver B1 type fractures which have undergone fixation. There is currently no guidance available on the next step of management for this patient group. This study presents a series of nine Vancouver B1 fractures with failed osteosynthesis and proposes that repeated fixation has poorer results than revision. METHODS: A total of nine patients (five women, four men) with a mean age of 71.2 years (52-83) underwent operative treatment for failed osteosynthesis of periprosthetic fractures of Vancouver type B1. Three patients were revised to a long revision stem while six patients had repeated osteosythesis. Failure was defined as the need for further operative intervention. RESULTS: The three patients revised to a long revision stem at first failure of osteosynthesis required no further surgical intervention. All six patients who had repeat osteoynthesis failed again. Five patients were subsequently successfully treated with revision of the primary stem, three were revised to a long revision stem while two patients required proximal femoral replacement. One patient died prior to revision. The mean follow up following initial B1 fracture was 49.3 months and following definitive operative intervention was 37.7 months. Six patients had died at 1st July 2017. CONCLUSION: Failed osteosynthesis of B1 fractures may necessitate revision rather than repeat fixation, regardless of how well fixed the stem appears. Revision to a long stem provided good results in this cohort.

Periprosthetic Fractures About the Hip: A Case-Matched Retrospective Analysis of Functional Outcomes Postrehabilitation.

INTRODUCTION: Little research has examined postrehabilitation functional outcomes of periprosthetic hip fractures. Predicted functional deficits and acceptable rehabilitation outcomes for these patients are not established. This study aimed to compare functional outcomes of periprosthetic fractures to matched patients with total hip arthroplasty (THA). MATERIALS AND METHODS: Cases with periprosthetic fracture (PPF) were matched for age, gender, and surgeon to primary THA cases. Only patients who had completed at least 1 year of rehabilitation were included. Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores were calculated for all surviving cases with PPF and primary THA. Secondary outcomes included length of stay and mortality. Statistical analysis was performed using Microsoft Excel and the 2-tailed Wilcoxon signed rank test. A P value of <.05 was accepted as indicative of statistical significance. RESULTS: We identified 25 patients with PPF. Three patients were unsuitable for functional assessment. Of the cases with PPF suitable for functional assessment, 14 (14/22) were male. The median age of the PPF and the THA groups was 71 years and 68 years respectively. The median WOMAC score for the PPF group was 26 (interquartile range [IQR] 5.5-49.5) compared to that of the primary THA group, 3 (IQR 2.0-24.5; P < .05). In the PPF group, there were 7 deaths and 3 of the surviving patients had significant complications. The median length of stay in the PPF group was 13 days (IQR 10.5-35) compared to the matched group of 5 days (IQR 5-8.5; P < .05). CONCLUSION: Patients with PPF have markedly poorer functional outcomes than age-, gender-, and surgeon-matched patients with THA as well as prolonged length of stay. Future research should target the identification of factors that may improve functional outcomes in this growing cohort.

Total knee replacement under tourniquet control: A prospective study of the peripheral arterial vasculature using colour-assisted duplex ultrasonography.

BACKGROUND AND PURPOSE: A tourniquet may potentiate rare and devastating arterial complications after total knee replacement (TKR) in patients with peripheral vascular disease (PVD). Most prior studies that evaluated peripheral arterial blood flow primarily used the ankle-brachial index (ABI). METHODS: We assessed the prevalence and risk factors for PVD in a cohort undergoing TKR. Clinical and radiological evaluations, including duplex ultrasonography, were performed one week prior to, and six weeks post-TKR performed under tourniquet control. Forty patients were analysed (20 male, 20 female; mean age 67 yrs, range: 53-80 yrs). MAIN FINDINGS: Hypertension (50%) and hypercholesterolaemia (50%) were the most common co-morbidities. Distal pulses were present in all patients preoperatively. Six patients (15%) had arterial calcification on their preoperative knee X-rays. Three patients (7.5%) had moderate PVD. There was no change in blood flow postoperatively in patients with or without PVD (p > 0.05). Vascular stenosis was less than 50% in all patients preoperatively and postoperatively. No postoperative vascular complications occurred. CONCLUSIONS: Severe PVD is not common in patients undergoing TKR. Performing total knee replacement under tourniquet control does not adversely affect the vasculature in patients with less than 50% vascular occlusion.

The conundrum of calcaneal spurs: do they matter?

BACKGROUND: Chronic plantar heel pain is a common and potentially debilitating condition, often caused by plantar fasciitis. Plantar calcaneal spurs were originally considered the cause of plantar fasciitis but are now regarded as an incidental finding by most authors. We aimed to test this hypothesis and to investigate predisposing factors for the development of spurs. METHODS: We reviewed all lateral ankle X rays taken in our institution over a 6-month period and identified all X rays demonstrating calcaneal spurs. Then, we identified a similar number of age- and sex-matched controls without spurs. We contacted both groups by telephone and compared symptoms of heel pain, plantar fasciitis, associated comorbidities, and foot and ankle outcome scores (FAOSs). RESULTS: We reviewed the X rays of 1103 consecutive patients and found a spur prevalence of 12.4%, more common in women and older patients. Questioning of the spur group and control group found a higher body mass index in the spur group. Patients with spurs were 4 times more likely to have diabetes mellitus and 10 times more likely to have lower-limb osteoarthritis. Patients with spurs had more foot pain and poorer FAOS than the control group, even when patients with plantar fasciitis were excluded. CONCLUSION: Our results demonstrate that the presence of a plantar calcaneal spur may be an indicator of foot pain independent of plantar fasciitis. Although spurs may not cause foot pain themselves, they may be an indication of other associated conditions. CLINICAL RELEVANCE: We have demonstrated the relevance of a radiographic finding once considered irrelevant.

Intra-articular dislocation of the patella.

We present an unusual case of a chronic, irreducible intra-articular dislocation of the patella in an elderly nursing home resident. The patient had been unable to weight bear for 3 weeks. Radiographs in the emergency department (ED) confirmed the intra-articular dislocation with the superior pole lodged in the intercondylar notch. She underwent two failed closed reduction attempts and subsequently required an open reduction under general anaesthesia.