Does the Schatzker III Tibial Plateau Fracture Exist?

Background: The Schatzker classification system for tibial plateau fractures is one of the most commonly used systems. However, there has been controversy if a Schatzker III type fracture truly exists by their original definition. We aimed to correlate the radiographic and CT images of type III fractures, describe the additional propagating fracture patterns and determine if these fractures do exist by their original description. Methods: This multicenter retrospective cohort observational study included patients with tibial plateau fractures across five trauma centers over 9 years were identified. All X-rays and CT scans were assessed. Two independent fellowship trained, Orthopaedic trauma surgeons reviewed all knee X-rays and classified them according to the Schatzker system. The CTs were subsequently reviewed and the fractures were reclassified based on CT findings. Results: 569 Tibial plateau fractures in 566 patients were analyzed. All X-ray classified Schatzker III fractures were reclassified to a Schatzker II type after review of CT scans by both assessors independently as there were always at least two or more fracture lines propagating from the depressed fragment to the lateral cortex in all cases. The interobserver variability as assessed by the kappa correlation coefficient (κ) for X-rays and CT-based classifications were κ = 0.274 and κ = 0.906, respectively. The majority of cases had two lateral cortical breaks (83.8%). In addition, the depression occurred mostly in the anterolateral and posterolateral positions (60.3%) of the lateral tibial plateau. Conclusion: This study did not support the existence of true Schatzker Type III fractures.

Social determinants of outcomes in nonoperatively treated proximal humerus fractures.

Background: Proximal humerus fractures (PHFs) are common fractures especially in the elderly, with most fractures being managed nonoperatively. Traditional biomedical factors such as radiological alignment have not been able to meaningfully predict comfort and capability after PHFs. Conversely, recent literature has increasingly recognized the role of psychological factors in determining comfort and capability after PHFs. Nonetheless, less is known about the impact of social factors. Additional study of these potentially modifiable social factors as targets for enhancing recovery from injury is merited. Among people recovering from a nonoperatively- treated proximal humerus fracture (PHF) we studied the social factors associated with patient-reported outcomes at 6 months and 1 year. Methods: One hundred seventy-one patients who received nonoperative management of a PHF completed baseline measures of sociodemographic characteristics (age, gender, race, employment status, household income, educational level, presence of domestic workers, housing type, and smoking status). Six and 12 months after fracture, participants completed the Oxford Shoulder Score (OSS), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) and EuroQol-5-Dimensions (EQ5D) measures of comfort and capability. The relationship between capability and social factors was assessed using linear regression modelling, accounting for potential confounding from age, fracture severity assessed using Neer classification, premorbid comorbidities measured by Charlson Comorbidity Index, and premorbid functional status measured by Parker Mobility Index and Barthel Index. Results: Lower capability (higher QuickDASH scores) 6 months and 1 year after fracture were associated with being unemployed (coef: -5.02 [95% CI: -9.96 to -0.07]; P = .047) and having domestic workers at home (coef: 8.63 [95% CI: 1.39 to 15.86]; P = .020), but not with Neer classification. Both greater shoulder discomfort and magnitude of incapability (lower OSS scores) and worse general quality of life (lower EQ5D scores) were associated with having domestic workers (coef: -4.07 [95% CI: -6.62 to -1.53]; P = .002 and coef: -0.18 [95% CI: -0.29 to -0.07]; P = .001 respectively) or living in an assisted care facility (coef: -14.82 [95% CI: -22.24 to -7.39]; P < .001 and coef: -0.59 [95% CI: -0.90 to -0.29] P < .001). Conclusions: The finding that people recovering from PHF experience less incapability in proportion to their social independence (employment, absence of a caregiver such as domestic workers at home and living outside care facilities) emphasizes the important associations of social factors to musculoskeletal health, and the utility of accounting for social factors in the development and assessment of care strategies.

The Evolution of Olecranon Fractures and Its Fixation Strategies.

Introduction: Olecranon fractures are a common fracture of the upper extremity. The primary aim was to investigate the evolution of olecranon fractures and fixation method over a period of 12 years. The secondary aim was to compare complication rates of Tension Band Wiring (TBW) and Plate Fixation (PF). Materials and Methods: Retrospective Study for all patients with surgically treated olecranon fractures from 1 January 2005 to 31 December 2016 from a tertiary trauma center. Records review for demographic, injury characteristics, radiographic classification and configuration, implant choices and complications. Results grouped into three 4-year intervals, analyzed comparatively to establish significant trends over 12 years. Results: 262 patients were identified. Demographically, increasing mean age (48.7 to 58.9 years old, p value 0.004) and higher ASA scores (7.1% ASA 3 to 21.0% ASA 3 p value 0.001). Later fractures were more oblique (fracture angle 86.1-100.0 degrees, p value 0.001) and comminuted (Schatzker D type 10.4-30.0%, p value 0.025, single fracture line 94.0-66.0%, p value 0.001). Implant choice, sharp increase in PF compared to TBW (PF 16.0% to PF 80.2%, p value 0.001). Complication-wise, TBW had higher rates of symptomatic implant, implant and bony failures and implant removal. Conclusion: Demographic and fracture characteristic trends suggest that olecranon fractures are exhibiting fragility fracture characteristics (older age, higher ASA scores, more unstable, oblique and comminuted olecranon fractures). Having a high index of suspicion would alert surgeons to consider use of advanced imaging, utilize appropriate fixation techniques and manage the underlying osteoporosis for secondary fracture prevention. Despite this, trends suggest a potential overutilization of PF particularly for stable fracture patterns and the necessary precaution should be exercised.

Effectiveness of anabolic steroids in improving outcomes for post-operative hip fracture patients: A randomized controlled trial.

Background: Post-operative elderly hip fracture patients require significant rehabilitation. Nandrolone is an anabolic steroid used to promote muscle growth. This study aims to examine the effect of nandrolone in improving rehabilitation and quality of life in elderly female patients with hip fractures undergoing hemiarthroplasty. Methods: This is a double-blinded prospective randomized-controlled-trial consisting of female patients above the age of 65 with an isolated neck of femur fracture planned for a hip hemiarthroplasty. Participants were randomized into two arms of the study - 50 mg intramuscular nandrolone vs normal saline placebo administered on post-operative day 0, and weeks 2, 6 and 12. The participants were followed up across a 1-year period following the surgery. Clinical outcomes such as time taken to achieve rehabilitation milestones, distance of ambulation and thigh muscle girth, and functional scoring with SF-36 questionnaire were recorded at intervals of 2, 6 and 12 weeks, 6 months and 1 year following the surgery. Results: There were a total of 23 subjects with 11 in the steroid group and 12 in the placebo group. There was no significant difference in demographics and injury patterns between both groups. There was no significant difference for time taken to achieve various rehabilitation milestones and distance of ambulation. SF-36 scores on discharge and at 1-year follow-up mark were comparable. There was no difference in the complication rate between both groups. Conclusion: Intra-muscular Nandrolone after hip surgery in elderly female patients does not result in short to mid-term improved rehabilitation or functional outcomes. Nandrolone did not result in increased short-term complications after hip surgery. Level of evidence: I.

Are Intertrochanteric Fractures Evolving? Trends in the Elderly Population over a 10-Year Period.

BACKGROUND: Intramedullary devices for the fixation of intertrochanteric fractures are increasing in usage and popularity. This reflects either a shift in adoption of new technology or intertrochanteric fractures becoming more complex or unstable. This trend was observed in our institution, hence we set out to investigate if this was concordant with an associated change in the demographics of the patients or in the morphology of the intertrochanteric fracture pattern over a 10-year period. METHODS: This is a retrospective cross-sectional comparison undertaken for the first 100 consecutive elderly patients with intertrochanteric fractures admitted to our tertiary institution over 3 yearly intervals, in each of the years 2004, 2007, 2010, and 2013. Fractures were radiologically classified via the Evans and AO classifications. Patient demographics such as age, ethnicity, and comorbidities and surgical data including time, type of fixation, time to surgery, and length of stay were collected via case note reviews to identify possible trends. RESULTS: The overall mean age was 80.5 years, with no statistically significant trend among age, sex, ethnicity, and comorbidities over the 10-year period. The main finding was a rise in the proportion of unstable intertrochanteric fractures. The proportion of such fractures was 30% in 2004, 42% in 2007, 47% in 2010, and 62% in 2013 (p < 0.001). Patients admitted for intertrochanteric fractures also experienced a shorter hospital length of stay and an increasing trend towards early fracture fixation (p < 0.001), with a greater usage of intramedullary nails in the treatment of such fractures (p < 0.001). CONCLUSIONS: Intertrochanteric fractures in elderly patients have evolved into more complex fractures over the past ten years, despite there being no change in the age of the patients over the same duration. This increasing proportion of unstable intertrochanteric fractures has brought about a greater tendency to fix these fractures with intramedullary implants.

After hours surgery for elderly hip fracture patients: How safe is it?

INTRODUCTION: The recent focus on early surgery for hip fractures to reduce complications and improve morbidity, has led some resource-constrained institutions to perform after hours surgery in a bid to meet these timelines. However, there are concerns about the potential increase in complications and poorer outcomes in after hours surgery. This study aims to evaluate the safety of after hours hip fracture surgery and its related complications. MATERIALS AND METHODS: This is a retrospective review of hip fracture patients admitted over a 2-year period to a tertiary centre with an established orthogeriatric co-managed hip fracture care pathway. Patients were divided into two groups based on their operating start time: (1) office hours surgery was defined as surgery conducted between 8 am to 5 pm on weekdays and 8 am to 12 noon on Saturdays; and (2) after hours surgery was defined as surgery conducted between 5 pm to 8 am on weekdays, and between Saturday 12 noon to Monday 8 am, as well as those that were conducted on public holidays. Demographic data, comorbidities, fracture details, operative details and outcome measures (complications, mortality and functional scores) were collated. RESULTS: A total of 903 patients were surgically treated for per- and intertrochanteric or femoral neck fractures. 76.7% (n = 693) of the patients underwent operation during office hours while 23.3% (n = 210) of the patients underwent after hours operation. 12.4% (n = 26) of the after hours group underwent surgery within 24 h of admission, compared with 6.8% (n = 47) in the office hours group (p = 0.009). We did not find any significant difference between the two groups in terms of complications, mortality and functional outcomes (p > 0.05). CONCLUSION: In conclusion, our study did not show that after hours surgery increases complication rates in hip fracture surgery and had equivalent functional outcomes.

A Novel Technique for Supplementing Transosseous Suture Repair of Inferior Pole Patella Fractures with a Tension Band.

INTRODUCTION: The transosseous suture fixation is a recognised surgical technique for inferior pole patella fractures. However, post-operative range of motion (ROM) is typically restricted to reduce complications of fracture displacement. We present a novel modified surgical technique using a supplemental Ethibond figure-of-eight stitch to reinforce the transosseous suture repair and studied its outcomes. We performed a retrospective study looking at outcomes of patients with displaced inferior pole patella fractures who underwent modified suture fixation from 2010 to 2018. OPERATIVE TECHNIQUE: In the modified suture fixation technique, after the standard transosseous repair was performed, the remnant Ethibond suture was placed in a figure-of-eight tension band fashion anteriorly across the patella. Immediate post-operative ROM was allowed if the fixation was stable. The patients were assessed up to 6 months post-surgery to monitor for fracture displacement/gap and for bony union. CASE SERIES: We analysed the results of 14 patients who underwent modified suture repair. All patients were allowed immediate post-operative ROM. Only 1 fixation failure (7%) was noted at 6 months. CONCLUSION: Complication rates were low with the modified technique even when patients were allowed immediate post-operative mobilisation. This shows greater confidence in the stability of the fixation and represents a viable technique for early mobilisation post-fixation of inferior pole patella fractures.

Outcomes after implementation of an open fracture clinical pathway.

INTRODUCTION: Open fractures are associated with high rates of complication, morbidity and high economic costs. To improve outcomes, an open extremity fracture clinical pathway that protocolized surgical management and encouraged multidisciplinary collaboration was implemented in our institution. This study evaluates the clinical outcomes before and after the implementation of the pathway. METHODOLOGY: Retrospective review of open tibial and femur fractures covering the 2 year periods before and after pathway implementation was conducted. Patient demographics, fracture location, fixation methods and Gustilo-Anderson classification type were recorded. Primary outcomes include complications of wound infection, implant infection, delayed/non-union and flap failure occurring in a 1 year follow-up period. Secondary outcomes include length of hospital stay, time from emergency department (ED) entrance to first wound debridement, time from ED to flap coverage and total number of operations required. RESULTS: A total of 43 pre-pathway and 46 post-pathway patients were included in this study. There was a significant reduction in length of hospital stay, a 37.5% decrease from a median of 11.2 to 7 days after pathway implementation. There was also a significant decrease in the number of fractures fixed with external fixators from 47 to 26%. No significant differences were found for the other secondary variables. In a subgroup analysis of type III fractures, there was a significant decrease in length of hospital stay as well as the number of operations required. Median length of hospital stay decreased by 46.7% from 15 to 8 days and total number of operations decreased by 50% from a median of four operations to two operations. CONCLUSION: This study demonstrates that the implementation of an open extremity fracture clinical pathway significantly reduces the proportion of external fixation surgeries, length of hospital stay, and number of operations in patients with open tibial and femur fractures, without compromising complication rates.

Functional outcomes after surgical treatment of tibial plateau fractures.

Tibial plateau fractures are significant because of its intra-articular nature. In this study, we aim to evaluate the functional outcomes of tibial plateau fractures after surgical treatment and to determine the rates of return to work and sports after recovery. This is a retrospective study conducted at a single tertiary-level institution. Forty-one patients with tibial plateau fractures were operatively treated during our study period. Patient information including injury mechanism, surgical treatment and associated injuries were documented. Pre-operative and post-operative radiographs were reviewed to confirm Schatzker type and adequacy of reduction. Follow up data for thirty-one patients was obtained nineteen to forty-two months post-surgery. All patients were administered functional outcome questionnaires using the Western Ontario and McMaster University Osteoarthritis index (WOMAC) and Short Form 36 (SF-36) general health survey. Data regarding return to work and sports was also collected. Data analysis was done to determine the relationship between fracture type, adequacy of reduction and functional outcome. The average WOMAC score for patients with Schatzker I to III was 6.3 out of a maximum score of 96, significantly lower than the Schatzker IV to VI group, whose average score was 18.4 (p = 0.0012). The SF-36 score for the Schatzker I to III group was also significantly higher than the VI to VI group (p = 0.0031). 71% of patients reported partial to full return to work, while 65% of patients did not return to sports after injury. In conclusion, the functional outcome of operatively treated tibial plateau fractures is satisfactory, with poorer functional outcome being associated with higher energy fractures. (Schatzker IV to VI) Majority of patients were able to return to their pre-injury employment but only a small minority were able to return to sports.

Intramedullary nailing of abnormally bowed atypical femoral shaft fractures: surgical technique.

The treatment of atypical femoral shaft fractures with abnormal bowing provides a unique challenge for surgeons. Whilst intramedullary fixation of atypical femoral shaft fractures affords both mechanical and biological benefits, the mismatch between standard intramedullary devices and the abnormal femoral bowing in these patients makes this method of fixation challenging for the surgeon. The purpose of this manuscript is to illustrate the evolution of our surgical technique through a series of four patients. The critical factors we identified include lateral positioning of the patient for reduction, the use of a piriformis-start nail, and an entry point that was anterior in the sagittal profile and lateral in the coronal profile. This technique was easily replicable, facilitated more anatomical reduction and aided in avoiding complications.

Hemiarthroplasty in the Hip Fracture Patient with Renal Impairment: To Cement or Not to Cement.

PURPOSE: Patients with chronic kidney disease (CKD) have a higher risk of complications when undergoing hip hemiarthroplasty. The primary aim is to test the null hypothesis that there is no difference between cemented and uncemented stem loosening rates in patients with CKD who receive a hip hemiarthroplasty for femoral neck fractures. The secondary aim is to determine the effect of increasing severity of renal disease on the rate of stem loosening in this CKD patient subset. MATERIALS AND METHODS: A retrospective study of all patients with CKD who underwent a hip hemiarthroplasty for a traumatic femoral-neck fracture between 2003 and 2013 was performed. Patients with a minimum of two-year follow-up were included; those with pathological fractures or loosening due to infection were excluded. The outcome measure was radiographic aseptic loosening of the stem, defined as progressive radiolucency of more than 2 mm, progressive subsidence or migration of the implant. RESULTS: One-hundred and nineteen cases were included in this study. Loosening occurred in 11 cases (9.24%). A comparison between cemented and uncemented groups revealed no difference in the rate of loosening (P=0.079). In all cases, worsening renal function did not increase the rate of loosening (P=0.311). The rate of loosening did not increase with worsening renal function in either the cemented (P=0.678) or uncemented groups (P=0.307). CONCLUSION: There is no difference in the rate of loosening between cemented and uncemented hemiarthroplasty for femoral neck fractures in the elderly with CKD. The rate of loosening did not increase with worsening renal function. All patients with renal impairment, not just those with end-stage renal failure, warrant close follow-up as early loosening can occur throughout the entire spectrum of renal disease.

Are Three-Dimensional Printed Models Useful for Preoperative Planning of Tibial Plafond Fractures?

Computed tomography (CT) scans with 3-dimensional (3D) reconstruction are the gold standard of imaging for complex fractures. However, visualising CT imaging can be challenging. With increasing access to 3D printing, we postulate that life-sized 3D models can better assist in visualising CT images, aiding preoperative planning of tibial plafond fractures. 3D models of 3 tibial plafond fractures of differing complexities were printed. We approached surgeons in our institution who manage tibial plafond fractures to complete a questionnaire on preoperative planning of the cases based on CT scans. We then examined whether analysing the 3D models after that changed the plan. This included ratings on the usefulness, accuracy, and ease of use of the models. Six surgeons participated in the study. In the simple fracture model, median usefulness was graded as 4.5 (range minimum to maximum: 0 to 7), accuracy 8 (4 to 10), and ease of use 9 (7 to 10) with 0 being the lowest and 10 being the upper limit of how useful, accurate, or easy to use the models were. For the intermediate fracture, median usefulness was 6.5 (2 to 8), accuracy 7.5 (3 to 10), and ease of use 8.5 (7 to 10). For the complex fracture, median usefulness was 6 (1 to 9), accuracy 7.5 (1 to 9), and ease of use 8.5 (0 to 9). We attribute these poorer scores to difficulty in processing the scans, resulting in less accurate printing of the many fragments in complex impacted fractures. In conclusion, 3D-printed models are easy to use and accurate in preoperative planning of tibial plafond fractures. Most surgeons believe that 3D models and CT scans combined were more useful than CT scans alone.

Management of elderly hip fractures by an orthopaedic trauma surgeon reduces surgical delays but does not improve outcomes compared to non-trauma surgeons.

PURPOSE: Recent literature on hip fractures has focussed on the optimal environment for best outcomes. One factor that has not been studied is the managing surgeon's training background. Our study aims to examine if hip fracture patients managed by fellowship-trained orthopaedic trauma surgeons have better outcomes compared to non-trauma trained general orthopaedic surgeons. METHODS: This is a retrospective study performed at a tertiary hospital with an established orthogeriatric co-managed hip fracture care pathway. All surgically treated elderly hip fracture patients over a period of 2 years were included and divided into 2 groups based on the managing surgeon: trauma and non-trauma. Patient characteristics, fracture and surgery information, post-operative complications, 1 year mortality and the Modified Barthel Index (MBI) scores were collected and compared. RESULTS: 871 patients were included. 32.1% (N = 280) were managed by trauma surgeons and 67.9% (N = 591) by non-trauma surgeons. There was no significant difference in the MBI scores pre-operatively and at 6 and 12 months post-operatively between the 2 groups. There was no difference in the incidence of postoperative complications and mortality. However, patients managed by trauma surgeons had significantly shorter time to surgery (p = 0.028) and higher proportion of surgeries performed within 48 h (p = 0.039). Trauma surgeons also took a shorter time to fix intertrochanteric fractures (p = 0.000). CONCLUSIONS: This study did not find any difference in the functional outcomes of hip fracture patients managed by trauma surgeons or non-trauma surgeons. However, trauma surgeons had faster times to surgery and shorter surgical times when fixing intertrochanteric fractures.

Fractures in patients with osteopetrosis, insights from a single institution.

PURPOSE: Osteopetrosis is a hereditary skeletal disorder in which defective osteoclast function leads to abnormally hard and brittle bones. This study aims to describe the pattern of fractures occurring in this group of patients, possible complications, and strategies to avoid them. METHODS: This is a case series of six osteopetrotic patients with a total of 12 fractures managed in our institution over a period of nine years. Patient records were also reviewed for complications both intra- and post-operatively. RESULTS: The majority of the fractures involved the femur, with three of these being peri-implant in nature. Other bones involved include the tibia, humerus, patella, fifth metatarsal, and proximal phalanx of the toe. There was a high rate of complications while managing these patients: three patients had peri-implant stress fractures, three with retained broken screws, and one case each of delayed union, non-union, and surgical site infection. CONCLUSION: Osteopetrosis fractures present a unique challenge to the orthopedic surgeon. Careful pre-operative planning should be undertaken before proceeding with surgery in these cases.

Outcomes of an accelerated nonsurgical management protocol for hip fractures in the elderly.

The majority of hip fractures in elderly patients are managed surgically with superior outcomes. However, for patients who refuse surgery or are deemed medically unfit, traction used to be the mainstay of nonsurgical treatment, which is associated with prolonged hospitalization and inpatient complications from immobility. This study, therefore, aims to evaluate the outcomes of an early wheelchair mobilization protocol as an alternative nonsurgical treatment option. This is a retrospective study of 87 elderly patients who were managed nonsurgically for their hip fractures over a 1-year period. The accelerated rehabilitation protocol did not have them on traction but were instead mobilized with assistance as soon as possible after admission. Variables collected electronically include patient demographics, fracture characteristics, inpatient mobilization milestones, inpatient complications, Modified Functional Ambulation Classification (MFAC), Modified Barthel Index (MBI) scores, and radiological findings. Patients who were younger, could sit up earlier and had a shorter length of stay, were able to ambulate better at 6 months ( p value < 0.05). Patients with femoral neck fractures and shorter length of stay had better MFAC scores. A total of 58% of patients with radiological follow-up had displacement of their fractures with age, type of fracture, and length of stay as predictors ( p value < 0.05) The Charlson's score, day to sitting up, and day to transfer affect fracture healing ( p value < 0.05). The mean length of stay was 17 days and the 1-year mortality was 18%. Surgical therapy remains the preferred choice of management for patients with hip fractures. Early wheelchair mobilization leads to a shorter length of stay compared to traditional traction methods and comparable 1-year mortality rates with operative management. Despite this, complication rates remain high and only 48% of patients achieved ambulation by 1 year, with healing in only 24% of fractures.

Is routine MRI necessary to exclude pathological fractures in patients with an oncological history?

INTRODUCTION: Magnetic resonance imaging (MRI) is the radiological modality of choice for diagnosing pathological fractures in situations of diagnostic uncertainty. With the increasing availability of MRI, we have observed a disturbing trend in utilising routine MRI scans to exclude pathological fractures in all patients with a history of cancer. The study objective was to determine if routine use of MRI scans in such patients is truly necessary and if other predictive factors can be utilised in lieu of the MRI scan. MATERIALS AND METHODS: A 3-year retrospective study was conducted reviewing all extremity MRI scans performed for suspected pathological fractures and compared to X-rays. All patients presented with an extremity fracture, a known diagnosis of solid organ cancer and had an MRI to determine if the fracture was pathological. Subjects were followed up with serial X-rays up to 1 year. RESULTS: 84 subjects were recruited. Comparing X-rays alone with MRI scans revealed 92% sensitivity and 98% specificity in detecting pathological fractures. Using X-rays in combination with an absent history of trauma increases the sensitivity to 100% but reduced the specificity to 91%. None of subjects in cancer remission had pathological fractures. CONCLUSIONS: MRI is an imperative tool for operative planning in pathological fractures; however, we recommend against the routine use of MRI to diagnose pathological fractures in oncological patients. Patients with solid organ cancer remission, a positive history of significant trauma prior to sustaining the fracture, and the absence of pathological features on plain radiographs are strongly predictive against pathological fractures.

Comparing Outcomes of Tumor Prosthesis Revision and Locking Plate Fixation in Supracondylar Femoral Periprosthetic Fractures.

BACKGROUND: Periprosthetic fractures around a total knee replacement (TKR) can be complex and difficult to manage, requiring the surgical expertise of the trauma and arthroplasty surgeon. There are a number of treatment modalities available, each with their own merits and limitations. As data on tumor prosthesis revision in periprosthetic fractures is sparse, this study aims to evaluate the results of revision using a tumor prosthesis and compare them with those of fixation using a locking plate in periprosthetic fractures after TKR. METHODS: This is a retrospective study of 15 patients who underwent either tumor prosthesis revision (n = 7) or locking plate fixation (n = 8) for supracondylar femoral periprosthetic fractures in our hospital from 2009 and 2014. The mean follow-up time for these patients was 44 months. This study's main outcome measures were pain relief, return to premorbid ambulatory function, and complications. RESULTS: The revision and fixation groups saw five versus three patients achieve pain relief (71.4% vs. 37.5%, p = 0.315), and two versus four patients return to their premorbid ambulatory function (28.6% vs. 50%, p = 0.608) at the follow-up, respectively. The mean time to weight-bearing in the revision group and fixation group was 2.9 days and 18.9 weeks, respectively (p = 0.001). There were eight complications seen in the revision group with none requiring reoperation; there were five complications seen in the fixation group, and two required reoperation. CONCLUSIONS: The results of revision TKR using a tumor prosthesis were comparable to those of fixation using a locking plate in periprosthetic fractures after TKR. Tumor prosthesis revision may be considered as a viable alternative to locking plate fixation when indicated.

Beyond comanaged inpatient care to community integration: Factors leading to surgical delay in hip fractures and their associated outcomes.

PURPOSE: Early surgery for older adults with hip fracture has been shown to improve outcomes. We aim to study the factors contributing to delay in surgery (defined as surgery performed more than 48 h after admission) and its associated outcomes in a tertiary hospital in Singapore with an integrated hip fracture program. METHODS: This is a prospective cohort study of hip fracture patients aged more than 60 years over 1 year. We collected data on demographics, premorbid mobility and functional status, time to surgery, postoperative complications, and inhospital mortality. Mortality data and functional performance were reviewed at 1 year. RESULTS: High American Society of Anaesthesiologists score independently predicted delay in surgery (odd ratio (OR) = 9.52, 95% confidence interval (CI): 1.69-53.68). Delayed surgery was significantly associated with longer length of stay (median 12.8 days with interquartile range (IQR) 9.7-17.6 days vs. 8.35 days with IQR 5.9-10.9 days, p < 0.01). Surgery within 48 h significantly reduced functional decline (Modified Barthel Index change -3.89 ± 17.23 vs. -9.29 ± 20.30, p = 0.01) and 1-year mortality (3.5% vs. 9.3%, p = 0.03). Surgical delay was an independent risk factor for early postoperative complications (OR = 3.21, 95% CI: 1.21-8.49), and patients were significantly less likely to return to premorbid mobility at 1 year (OR = 0.62, 95% CI: 0.39-0.97). CONCLUSIONS: Delayed hip fracture surgery in older adults is associated with worse short- and long-term outcomes, including early postoperative complications and poorer functional recovery.