Clinical outcomes and hospital length of stay in 2,756 elderly patients with hip fractures: a comparison of surgical and non-surgical management.

INTRODUCTION: The purpose of this study was to compare the clinical outcomes of elderly hip fracture patients who received surgical treatment with those who received non-surgical treatment. METHODS: This retrospective study involved 2,756 elderly patients with hip fractures who were admitted over a six-year period. The patients' biodata, complications, ambulatory status at discharge and length of hospital stay were obtained from the institution's hip fracture registry. RESULTS: Among the 2,756 hip fracture patients, 2,029 (73.6%) underwent surgical intervention, while 727 (26.4%) opted for non-surgical intervention. The complication rate among the patients who underwent surgical intervention was 6.6%, while that among the patients who underwent non-surgical intervention was 12.5% (p < 0.01). The mean length of hospital stay for the surgical and non-surgical hip fracture patients was 15.7 days and 22.4 days, respectively (p < 0.01). CONCLUSION: Surgical management of hip fractures among the elderly is associated with a lower complication rate, as well as a reduced length of hospital stay.

Clinical outcomes and hospital length of stay in 2,756 elderly patients with hip fractures: a comparison of surgical and non-surgical management

<p><b>INTRODUCTION</b>The purpose of this study was to compare the clinical outcomes of elderly hip fracture patients who received surgical treatment with those who received non-surgical treatment.</p><p><b>METHODS</b>This retrospective study involved 2,756 elderly patients with hip fractures who were admitted over a six-year period. The patients' biodata, complications, ambulatory status at discharge and length of hospital stay were obtained from the institution's hip fracture registry.</p><p><b>RESULTS</b>Among the 2,756 hip fracture patients, 2,029 (73.6%) underwent surgical intervention, while 727 (26.4%) opted for non-surgical intervention. The complication rate among the patients who underwent surgical intervention was 6.6%, while that among the patients who underwent non-surgical intervention was 12.5% (p < 0.01). The mean length of hospital stay for the surgical and non-surgical hip fracture patients was 15.7 days and 22.4 days, respectively (p < 0.01).</p><p><b>CONCLUSION</b>Surgical management of hip fractures among the elderly is associated with a lower complication rate, as well as a reduced length of hospital stay.</p>

Correlation between the distal anterior femoral cortical axis and femoral rotational alignment: an anatomic study.

PURPOSE: To determine the correlation between the distal anterior femoral cortical axis (DAFCA) and the femoral rotational alignment/axis. METHODS: Magnetic resonance images (MRI) of 82 knees in 34 men and 23 women aged 16 to 47 (mean, 33.4) years were reviewed by a musculoskeletal radiologist. Their diagnoses included meniscal tear (n=4), chondromalacia (n=25), anterior cruciate ligament tears (n=11), and normal (n=42). In all patients the collateral ligaments were intact. The transepicondylar axis (TEA), posterior condylar axis (PCA), Whiteside line (WL), and joint line were drawn on the images, and the condylar twist angle (CTA), TEA-WL angle, DAFCA, epicondylar cortical angle (ECA), and condylar cortical angle (CCA) were measured. The correlations among ECA, CCA, and CTA (control) were assessed. RESULTS: The mean distances between the joint line and the TEA, PCA, and DAFCA were 30.8, 22.1, and 62.2 mm, respectively. The angles subtended by the intersection between the standard axes (TEA, PCA, and WL) and the DAFCA were determined. There was correlation between the CTA and ECA (r=0.34, p<0.05), between the ECA and the CCA (r=0.80, p<0.0001), and between the CTA and the CCA (r=- 0.19, p=0.08). CONCLUSION: There was correlation between the DAFCA and TEA and PCA; DAFCA can be used to determine the femoral rotational alignment when the standard landmarks are distorted by severe soft tissue and bone loss.

Risk factors for early implant-related surgical site infection.

PURPOSE: To identify the risk factors and microbes associated with early implant-related surgical site infection (SSI). METHODS: Records of 193 implant-related SSIs secondary to primary orthopaedic surgery were reviewed. Early and late SSI was defined as infection diagnosed within and after 3 months of surgery, respectively. RESULTS: Of the 193 implant-related SSIs, 29 were superficial incisional, 127 were deep incisional, and 37 were organ/space-related. 144 (90%) out of 160 SSIs used cefazolin in their prophylactic antibiotic regimen. In univariate analysis, early SSI was associated with diabetes mellitus, American Society of Anesthesiologists (ASA) score of >2, emergency procedures, and lack of antibiotic prophylaxis. In multivariable analysis, early SSI was associated with an ASA score of >2 (p=0.016). CONCLUSION: It is important to cross-check ASA score with co-morbidities to reduce early SSIs. Peri-operative optimisation and antibiotic prophylaxis should be administered prior to surgery. Appropriate modification of antibiotic prophylaxis should be considered.

Use of tantalum cones in primary arthroplasty of acute proximal tibial fractures.

Metaphyseal tantalum cones in primary total knee arthroplasty and their functional outcome is described using 3 case reports over 6 years. 3 knees in 3 elderly individuals (mean age of 70.4 years), with pre-existing osteoarthritis and complex proximal tibial fractures, were operated on. Ambulation with walking frame was achieved from post-operation day 1, with weight-bearing as tolerated. Mean range of motion was 122° and Mean Knee Society Score was 88. All showed improvement in pre-operative limb alignment. Radiological fracture union was achieved on an average of 3 months. All were independent ambulators and pain-free at the latest follow-up. Our case series shows that tantalum cones are associated with significant improvements in clinical scores, patient symptoms, range of movement, early weight-bearing and low rates of complications in complex proximal tibial fractures with poor bone stock.

Alignment Analyses in the Varus Osteoarthritic Knee Using Computer Navigation.

Osteoarthritic (OA) knees with severe extension varus deformity seem to have correspondingly more severe flexion varus, especially beyond a certain tibiofemoral angle. Clinical measurement of flexion varus and fixed flexion deformity (FFD), which had been difficult to perform because of the spatial alignment of the knee in flexion, was recently made possible with computer navigation. We conducted a study to evaluate the relationship of extension and flexion varus in OA knees and to determine whether severity of FFD in the sagittal plane correlates with severity of coronal plane varus deformity. The study included 317 consecutive cases of computer-navigated total knee arthroplasty performed on OA knees with varus deformities. Three sets of values were extracted from the navigation data: varus angle at maximal knee extension, 90° knee flexion, and maximal knee extension. Correlation analyses were performed for extension and flexion varus, FFD, and coronal plane deformity. OA knees with extension varus of more than 10° had an incremental likelihood of more severe flexion varus. When the extension varus angle exceeded 20°, probability became almost certainty. There was no correlation between FFD and coronal plane varus deformity.

Synovial Cyst: A Culprit for Recalcitrant Iliotibial Band Syndrome: A Case Report.

We present the case of a 56-year old gentleman who presented with recalcitrant iliotibial band (ITB) friction syndrome which did not improve with various modalities of conservative treatment. Magnetic Resonance Imaging (MRI) of the affected knee did not show pathology typical of ITB friction syndrome. However, open exploration revealed a synovial cyst deep to the iliotibial band, abutting against the anterolateral capsule. The presence of distinctive clinical signs on physical examination should alert clinicians to consider knee synovial cyst as a differential diagnosis when dealing with recalcitrant ITB syndrome.

Painful pretibial pseudocyst at bioabsorbable interference screw aperture two years after anterior cruciate ligament reconstruction.

We report the case of a patient with a painful subcutaneous nodule, measuring 13 mm × 17 mm, at the pretibial graft aperture site, which presented two years after a successful anterior cruciate ligament reconstruction with an autologous hamstring graft. A bioabsorbable poly-L-lactide interference screw was used for graft fixation at the tibial aperture. The patient underwent surgical excision of the lesion and curettage at the tunnel aperture. Grossly, extruded fragments of the screw and a thick pseudocapsule of surrounding tissue were excised. There was no communication between the tunnel aperture and the knee joint. The graft was also intact. Histological analysis revealed fragments of the bioabsorbable material in association with fibrous and granulomatous chronic inflammatory cells. This was consistent with a foreign body reaction. The patient subsequently recovered and resumed preinjury level of activity. To the best of our knowledge, this is the first report describing a nodular granulomatous type reaction to foreign bioabsorbable poly-L-lactide screw material subsequent to an anterior cruciate reconstruction surgery.

Role of navigated total knee arthroplasty for acute tibial fractures in the elderly.

PURPOSE: The role of total knee arthroplasty (TKA) in acute tibial fractures with existing comminution/bone loss, osteoporosis or preexistent arthritis has been described in the literature. Many of these procedures necessitate the use of stems to off-load the component and augments/wedges to avoid overresection and hence restore the joint line. Conventional methods may not be consistently accurate in restoring the desired alignment within 3° of the anatomical axis in this complex scenario. Computer-assisted TKA has been demonstrated to reproducibly and accurately restore the mechanical axis and joint line in primary TKA. Literature review has sparse data on use of navigation in acute TKA. METHODS: 9 cases of acute tibial fractures (6 tibial plateau and 3 diaphyseal) were treated by navigated primary knee arthroplasty and followed up over 26-month duration. RESULTS: All fractures healed without notable complications. Mean range of movement was 114°. Mean Knee Society score was 84. Out of 9 cases 5 were graded as excellent, 3 good and 1 fair. All knees were corrected to within a mean of 1.7° of the calculated mechanical axis. CONCLUSION: Total knee arthroplasty should be considered a treatment option for acute upper tibial fractures in the elderly with coexistent knee arthritis and poor bone stock. Computer-assisted navigation aids in restoration of mechanical axis and component positioning.

The application of minimally invasive surgical techniques. Part I: total hip arthroplasty.

Traditional surgical approaches often involve making large skin incisions and extensively dissecting healthy tissue to access diseased anatomy. Obviously more desirable is to make smaller incisions and more focused dissections and achieve the same postsurgical outcomes. Minimally invasive surgery (MIS) is gaining popularity in many orthopedic fields, but MIS techniques are not without risk. Continued use of these techniques is a topic of debate. If satisfactory alignment is satisfactory with MIS, and if the complication rates of MIS are similar to those of traditional approaches, it seems sensible to consider the less invasive approaches to enable earlier patient recovery and improve cosmesis. Skeptics claim that there is no advantage in using MIS over time-tested approaches and are concerned that MIS approaches are being implemented before being properly subjected to peer review.

The application of minimally invasive surgical techniques. Part II: total knee arthroplasty.

Traditional surgical approaches often involve making large skin incisions and extensively dissecting healthy tissue to access diseased anatomy. Obviously more desirable is to make smaller incisions and more focused dissections and achieve the same postsurgical outcomes. Minimally invasive surgery (MIS) is gaining popularity in many orthopedic fields, but MIS techniques are not without risk. Continued use of these techniques is a topic of debate. If alignment is satisfactory with MIS, and if the complication rates of MIS are similar to those of traditional approaches, it seems sensible to consider the less invasive approaches to enable earlier patient recovery and improve cosmesis. Skeptics claim that there is no advantage in using MIS over time-tested approaches and are concerned that MIS approaches are being implemented before being properly subjected to peer review.

Applying computer-assisted navigation techniques to total hip and knee arthroplasty.

Appropriate implant alignment is a major goal of total joint arthroplasty. Obtaining appropriate alignment typically involves making intraoperative decisions in response to visual and tactile feedback. Integrated computer-based systems provide the option of continuous real-time feedback and offer the potential to decrease intraoperative errors while enhancing the surgical learning experience. Computer-assisted orthopedic surgery helps the surgeon perform both intraoperative and postoperative technical audits of implant alignment. Improving implant alignment can be correlated with improved long-term clinical outcomes. However, despite emerging data, many surgeons remain wary of computer-assisted orthopedic surgery.

Total hip arthroplasty in above-knee amputees: a case report.

There are previous case reports in the literature that describe total knee and total hip arthroplasty (THA) in below-knee amputees, but we could find no case reports on above-knee amputees (AKAs) who have severe osteoarthritis of the hip. We present a case involving an AKA who developed severe osteoarthritis of the ipsilateral hip. Out patient underwent THA with a satisfactory postoperative outcome. Technical considerations for AKAs undergoing THA are also reviewed.

Management of knee osteoarthritis presenting with tibial stress fractures.

Stress fractures of the tibia secondary to tibial deformities from osteoarthritis are rare, and may be difficult to manage. We treated two patients with stress fractures of the proximal tibial diaphyses over a period of two years. Both patients had osteoarthritis of the knee; one with genu valgus deformity and the other, genu varus deformity. The former patient also had a distal tibial fracture and had previously undergone open reduction and internal fixation. The stress fractures of both the patients had been treated conservatively by nonoperative means, but their fractures failed to unite. They then underwent a modular total knee prosthesis with a long tibial stem extension, and subsequently, their fractures united. Both patients recovered uneventfully.

Operative fixation of a subtrochanteric fracture in a patient with previous spontaneous hip fusion.

Patients with a fused hip can present with various clinical problems, such as contralateral hip arthritis, ipsilateral knee arthritis and degenerative disc disease. There are significant deforming forces at the proximal femur in patients with a fused hip who have ipsilateral subtrochanteric fractures. We report a 66-year-old patient with a spontaneously fused right hip, who sustained an ipsilateral comminuted proximal femoral fracture secondary to a road traffic accident. Optimal operative fixation of this patient posed as a surgical challenge. We discuss the management options in this paper. Intramedullary nailing was used so as to minimise the blood loss and because of its favourable biomechanical characteristics. The patient had postoperative femoral nerve neuropraxia that eventually resolved. In patients with a fused hip who have ipsilateral subtrochanteric fractures, retrograde nailing of such fractures can serve as an optimal treatment option. However, femoral nerve palsy can be a potential complication.

Massive wear and metallosis of an Acetabular Cup System presenting as pseudodislocation.

In primary and revision total hip arthroplasty (THA), the acetabular component continues to pose greater challenges than the femoral component. Numerous factors lead to polyethylene wear, which subsequently affects primary THA survival. Progressive polyethylene wear is associated with the occurrence of osteolysis, especially overlying the acetabulum, which can lead to component loosening and subsequent revision. Polyethylene failure usually manifests as massive liner wear up to the metal shell, fracture of the liner, or a combination of both. There is often a small amount of metallosis associated with this pathology. To our knowledge, massive wear of the acetabular metal shell, however, has not previously been reported in the literature. This article describes a case of massive wear through a polyethylene liner and the acetabular metal shell of an Acetabular Cup System (DePuy, Leeds, United Kingdom) that presented as an apparent dislocation 13 years following the index operation. The pseudodislocation was intraoperatively found to be penetration of the femoral head through the acetabular shell. The acetabular component was consequently revised to a larger cementless cup. The femoral component was mechanically stable and required no revision. Patients with long-standing Acetabular Cup System THA may experience acetabular metal shell wear-through phenomena presenting as a pseudodislocation, and this possibility should be taken into consideration during preoperative planning.

Management of gamma nail breakage with bipolar hemi-arthroplasty.

Gamma nail breakage is an uncommon occurrence that often arises from fatigue failure of the implant, with a reported incidence ranging from 0.2 to 5.7 percent. We report a 73-year-old woman with a three-part intertrochanteric fracture and who presented two years postoperatively with gamma nail failure secondary to fracture non-union. This patient underwent a revision long-stem bipolar hemi-arthroplasty and has been followed-up for 24 months, with good functional and radiological results.

The epidemiology and surgical outcomes of patients undergoing primary total hip replacement: an Asian perspective.

INTRODUCTION: The number of total knee replacements far exceeds the number of primary total hip replacements (THR) in Singapore. There is a paucity of data regarding patients who undergo THR in Singapore. This paper aimed to study the epidemiology and early postoperative outcomes of patients receiving primary THR in a single tertiary institution. METHODS: This is a retrospective study of all patients undergoing primary THR between January 2003 and December 2005. The following variables were analysed: patient demographics, surgical approach, mode of implant fixation, postoperative complications and functional outcomes using D'Aubigne and Postel scoring. RESULTS: There were a total of 115 patients who underwent primary THR over a 36-month period. The mean age of patients was 55 (range 23-80) years. The male-to-female ratio was 1:2. The most common diagnoses in descending order were as follows: inflammatory arthritis, osteoarthritis, avascular necrosis, hip dysplasia and post-traumatic osteoarthritis. Patients were evaluated at a mean follow-up of 41 months, with 90.8 percent having excellent and good outcomes. There were no statistical differences between the surgical approach and implant fixation with regard to postoperative outcome. CONCLUSION: In Asian patients, the three commonest aetiologies for degenerative hip arthritis were inflammatory arthropathies, primary osteoarthritis and avascular necrosis. Regardless of diagnosis, the patient groups had comparable functional outcomes following THR.

Does stress shielding occur with the use of long-stem prosthesis in total knee arthroplasty?

A retrospective study conducted to evaluate the possible occurrence of stress shielding with the use of long-stem tibial prosthesis in total knee arthroplasty. Forty-one patients were reviewed (twenty-three standard prosthesis, eighteen long-stem prosthesis) and forty-one unoperated knee of the contralateral limb). Patients underwent bone mineral density assessment with a dual-energy X-ray absorptiometry (DEXA) bone densitometer for the hip and bilateral knees. The mean time interval between surgery and the DEXA assessment was 87.7 months. There was no significant statistical difference (P > 0.05) in the bone mineral density patterns of the tibia with the use of either standard or long-stem prosthesis. The utilization of the long-stem prosthesis to off-load the tibia is not associated with any significant bone mineral density changes or stress shielding.