Factors affecting healing and progression of conservatively treated incomplete atypical femoral fractures: retrospective observational study.

INTRODUCTION: Incomplete atypical femoral fractures (iAFF) may occur with prolonged bisphosphonate usage. Factors influencing iAFF healing and progression are not well understood. This study of conservatively managed iAFF assessed factors influencing iAFF healing and progression including the effects of bisphosphonates and teriparatide use. MATERIALS AND METHODS: Single-center retrospective observational study of 69 consecutive patients with 78 radiographically confirmed iAFF from 2002 to 2017. Serial radiographs assessed for focal cortical thickening, dreaded black line (DBL) and complete fracture. Chief outcome measures were DBL healing and complete fracture. RESULTS: DBL had a significant association (p < 0.05) with fracture progression by multivariable logistic regression (55.8% versus 25.7%, odds ratio [OR] 26.57 (95% CI 1.40-504.78)) and shorter fracture-free survival (mean 3.21 versus 6.27 years). Presence of symptoms was associated with shorter fracture-free survival (mean 2.68 versus 5.98 years). Discontinuing bisphosphonates had significant associations (p < 0.001) by multivariable logistic regression with decreased fracture rate (11.6% versus 92.0%; OR 0.00, 95% CI 0.00-0.08) and longer fracture-free survival (mean 7.52 versus 1.99 years). DBL healing occurred in 36.4%, only when bisphosphonates were discontinued. Age, sex, race, fracture site, glucocorticoid use, teriparatide supplementation and duration of bisphosphonate use showed no statistically significant effect although teriparatide use appeared to improve DBL healing (50% versus 17.9%, p = 0.188). CONCLUSIONS: In conservatively managed iAFF, DBL healing occurred in 36.4% if bisphosphonates were discontinued. Bisphosphonates and DBL were significantly associated with fracture progression and together with symptoms with fracture survival.

Bilateral Atypical Femur Fractures After Denosumab in a Bisphosphonate Naive Patient: A Case Report.

A case report of bilateral atypical femur fractures (AFF) in a bisphosphonate naive patient. A 62-year-old female bisphosphonate naive patient was started on denosumab for osteoporosis. Approximately 3 years later she complained of right hip pain and was found to have a bilateral incomplete AFFs. She was asymptomatic on the left lower limb. Patient was managed conservatively and placed on protected weight bearing on both legs. Symptoms subsequently resolved over a period of 3 months, although radiographic findings remained at approximately 1 year. AFFs may be associated with patients on denosumab therapy even without a prior history of bisphosphonate use. Patients should be counselled appropriately and monitored for such complications.

Early Postoperative Pain After Total Knee Arthroplasty Is Associated With Subsequent Poorer Functional Outcomes and Lower Satisfaction.

BACKGROUND: There are few studies investigating the effects of acute postoperative pain on functional outcomes after total knee arthroplasty (TKA). The aims of this study are to identify perioperative factors associated with increased early postoperative pain and investigate the effects of acute postoperative day 1 and 2 pain on outcomes at 6 months and 2 years post-TKA. METHODS: 1041 unilateral TKA patients were included in this retrospective cohort study. Patients were categorized into minor (visual analog scale: VAS <5) and major (VAS ≥5) pain groups based on postoperative day 1/2 VAS scores. Patients were assessed preoperatively, at 6 months and 2 years using Knee Society Knee Score and Function Scores (KSFS), Oxford Knee Score (OKS), SF-36 physical and mental component score (SF-36 PCS), expectation and satisfaction scores. Perioperative variables including age, gender, race, body mass index, American Society of Anesthesiologist status, type of anesthesia, and presence of caregiver were analyzed as predictors of postoperative acute pain. Wilcoxon two-sample test was used to analyze outcomes significantly associated with "major pain." Multiple logistic regression was used to identify predictors of "major pain." RESULTS: Patients with "minor pain" had significantly better KSFS, Knee Society Knee Score, OKS, and SF-36 PCS scores at 6 months and significantly better KSFS, OKS, SF-36 PCS, and satisfaction at 2 years (P < .05). A significantly higher percentage of patients with "minor pain" met the minimal clinically important difference for SF-36 PCS at 6 months and KSFS at 2 years (P < .05). Women, Indian/Malay race, higher BMI, and use of general over regional anesthesia were independent predictors of getting "major pain" (P < .05). CONCLUSION: Patients should be counseled about risk factors of postoperative pain to manage preoperative expectations of surgery. Patients should be managed adequately using multimodal pain protocols to improve subsequent functional outcomes while avoiding unnecessary opioid use.

Sub-optimal serum 25-hydroxyvitamin D level affects 2-year survival after hip fracture surgery.

INTRODUCTION: Hypovitaminosis D is a common condition seen in patients with acute hip fracture. We hypothesize that in addition to the other prognosticating factors, hypovitaminosis D may affect survival in patients treated for hip fractures. The objective of this study is to evaluate the impact of serum level of 25-hydroxyvitamin D (25(OH)D) on the survivability after surgical fixation of hip fractures. MATERIALS AND METHODS: We retrospectively studied data collected from January 2013 through December 2015 at a large tertiary hospital in Singapore. Patient's age, gender, Charlson Comorbidity Index (CCI), delay of surgery, fracture patterns, ASA score, as well as their pre-operative serum levels of 25(OH)D, albumin and calcium were examined. Univariate and multivariate logistic regression were used to analyse post-operative outcomes including short (inpatient, 30 and 90 days) and long-term mortality (2 years). RESULTS: Data from 1004 patients were used. Information on the serum level of 25(OH)D was available in 80% of them (n = 801) and more than 90% (n = 735) of the patients had a baseline serum level of less than 30 ng/ml. Mortality rate within this group were 1.1% (n = 9) at 30 days, 1.9% (n = 15) at 90 days and 11.0% (n = 88) at 2 years follow up. Hypovitaminosis D was not a significant risk predictor for short-term mortality, but found to be a significant predictor at 2 years. CONCLUSIONS: In this study, we showed a high prevalence of hypovitaminosis D among the osteoporotic hip fracture population and its impact on 2-year survivorship after hip fracture surgery.

The effect of the comorbidity burden on vitamin D levels in geriatric hip fracture.

BACKGROUND: Elderly patients with hip fractures often have multiple medical comorbidities, and vitamin D deficiency is common in this population. Accumulating evidence links low vitamin D levels to various comorbidities. However, very little is known about the collective impact of comorbidities on vitamin D levels. The Charlson Comorbidity Index (CCI) is a validated comorbidity burden index. We hypothesized that a high CCI score is associated with vitamin D deficiency in elderly patients with hip fracture. METHODS: A retrospective cohort study was conducted among all hospitalized elderly patients aged > 60 years admitted for low-energy hip fracture in a single tertiary hospital from 2013 to 2015. Data regarding patient demographics, fracture type, serum 25-hydroxyvitamin D3 levels and age-adjusted CCI score were collected and analysed. RESULTS: Of the 796 patients included in the study, 70.6% (n = 562) of the patients were women and the mean age was 77.7 ± 8.0 years. The mean vitamin D level was 20.4 ± 7.4 ng/mL, and 91.7% ofhospitalized elderly patients with hip fracture had inadequate vitamin D level. There was no correlation between the individual serum vitamin D level with respect to age-adjusted CCI (Pearson correlation coefficient = 0.01; p = 0.87). After stratifying the CCI scores into low and high comorbidity burden groups (i.e., with scores 1-2 and ≥ 3), there was no relationship between the 2 subgroups for age-adjusted CCI and vitamin D levels (p = 0.497). Furthermore, there was also no association among age, gender, fracture type, and smoking status with the mean 25(OH)D level (p > 0.05). CONCLUSION: Low vitamin D levels were highly prevalent in our hip fracture cohort. There was no relationship between the CCI score and vitamin D levels in the geriatric hip population. The comorbidity burden in geriatric patients with hip fractures did not seem to be a significant factor for vitamin D levels.

Comorbidity as the dominant predictor of mortality after hip fracture surgeries.

The aim of this study was to investigate the association of surgical delay and comorbidities with the risk of mortality after hip fracture surgeries. We found that CCI was the dominant factor in predicting both short- and long-term mortality, and its effect is vital in the prognostication of survivorship. INTRODUCTION: Hip fracture is a growing concern and a delay in surgery is often associated with a poorer outcome. We hypothesized that a higher Charlson Comorbidity Index (CCI) portends greater risk of mortality than a delay in surgery. Our aim was to investigate the associations of surgical delay and CCI with risk of mortality and to determine the dominant predictor. METHODS: This retrospective study examines hip fracture data from a large tertiary hospital in Singapore over the period January 2013 through December 2015. Data collected included age, gender, CCI, delay of surgery, fracture patterns, and the American Society of Anaesthesiologist (ASA) score. Post-operative outcomes analyzed included mortality at inpatient, at 30 and 90 days, and at 2 years. RESULTS: A total of 1004 patients with hip fractures were included in this study. Study mortality rates were 1.1% (n = 11) during in-hospital admission, 1.8% (n = 18) at 30 days, 2.7% (n = 27) at 90 days, and 13.3% (n = 129) at 2 years. Lost to follow-up rate at 2 years was 3.3%. We found that CCI was consistently the dominant factor in predicting both short- and long-term mortality. A CCI score of 5 was identified as the inflection point above which comorbidity at baseline presented a greater risk of mortality than a delay in surgery. CONCLUSION: Our analysis showed that CCI is the dominant predictor of both short- and long-term mortality compared with delay in surgery. The effect of CCI is vital in the prognostication of mortality in patients surgically treated for hip fractures.

What Are the Preoperative Outcome Measures That Predispose to Periprosthetic Fractures After Primary Total Knee Arthroplasty?

BACKGROUND: There is little known in the literature about whether preoperative patient-reported outcome measures (PROMs) would affect the risk of periprosthetic fractures (PPFs) after primary total knee arthroplasty (TKA). Our study aims to evaluate the predictive values of PROMs on PPF after primary TKA. We hypothesize that poorer PROMs are associated with a higher risk of PPF after primary TKA. METHODS: We reviewed prospectively collected data in our hospital arthroplasty registry. Patients who sustained PPF after primary TKA between 2000 and 2015 were identified. Forty-two patients were identified and matched for gender, age, and body mass index to a control group of 84 patients who had primary TKA without PPF in a 2:1 ratio. Preoperative demographics, Short Form-36 (SF-36) scores, Oxford Knee score and Knee Society Score were evaluated. Variables of PROMs were entered into a multivariate logistic regression model. A variable was considered to be a significant predictor if its odds ratio was significant at P < .05. RESULTS: After multivariate regression analysis, SF-36 subdomains of physical functioning (PF) and vitality (VT) were identified as significant predictors for PPFs after primary TKA. A lower SF-36 PF and VT scores were associated with higher risks of sustaining a PPF after primary TKA. CONCLUSION: From our study, low preoperative SF-36 PF and VT scores are associated with a higher risk of PPFs after primary TKA. These results can allow the preoperative identification of patients at higher risk of PPF, and appropriate preoperative counseling, optimization, and close follow-up can be instituted for this at-risk group.

Bisphosphonate-associated peri-implant fractures: a new clinical entity? A series of 10 patients with 11 fractures.

BACKGROUND AND PURPOSE: The current definition of atypical femoral fractures (AFFs) associated with bisphosphonate use includes only de novo fractures. However, in recent years reports of bisphosphonate-associated periprosthetic fractures involving stemmed arthroplasty implants have emerged. In a case series of peri-implant fractures in femurs with plate/screw constructs, we aimed to assess similarities with classical AFFs and how their location may have implications for the pathogenesis and management of AFFs. PATIENTS AND METHODS: We retrospectively identified 10 patients with 11 peri-implant fractures. RESULTS: The patients were ambulant women, mean age 80 (70-92) years. Mean duration of bisphosphonate use was 5 (1-10) years. The peri-implant fractures were sustained an average of 4 years (6 months to 9 years) from the time of index surgery. They were all associated with low-energy mechanisms. 8 fractures occurred near the tip of a plate, while 3 traversed the penultimate screwhole of a plate. The peri-implant fractures showed clinical and radiological features of atypicality such as lateral cortical thickening, simple fracture pattern, and lack of comminution. The patients underwent revision surgery, with bone grafting used in all but 1 case. Radiological union was evident after 2-4 months. INTERPRETATION: Atypical peri-implant fractures of the femur associated with bisphosphonate use may be a new entity. Stress lesions and atypical fractures may tend to develop over stress risers along the operated femur. This finding has implications for the pathogenesis and clinical management of AFFs.

Reduction of geometric misfit in straight antegrade humeral nailing by evaluating the effect of entry point angulation using a three-dimensional computational analysis.

BACKGROUND: Straight antegrade intramedullary nails are generally inserted utilising the apex as the surgical entry point in accordance with the mechanical axis of the bone. Our objective is to optimise the bone-nail fit in intramedullary nailing by subjecting the surgical entry point to varying angulations in both the mediolateral and anterior-posterior directions via a quantitative fit assessment in each configuration to identify the optimal angulation, defined as the angulation with the lowest occurrence of thin-out to improve nail fitting within the humerus. METHODS: Computed tomography (CT) scans from 10 cadaveric humeri models were used to generate three-dimensional bone models. The centreline profile of each humerus model was determined by dividing the humerus into multiple slices and identifying its respective centroid. The guidewire and nail models were then established and inserted into the humerus using the apex as the standard entry point. The bone-nail fit was measured utilising three fit quantification parameters: thin-out distance, nail protrusion volume into the cortical shell and deviation distance (top, middle, bottom) between the nail's longitudinal axis and medullary cavity centroid. FINDINGS: Results revealed a statistically significant association between angulation and occurrence of thin-out (p < .001) and showed that the optimally angulated entry point resulted in decreased cortical breach across the nail insertion depth compared to the standard entry point. INTERPRETATION: Our findings suggested that the current straight nail design may require further modifications to optimise the nail trajectory within the medullary canal by decreasing the bone-nail geometric mismatch to potentially maximise its working length.

Incomplete Periprosthetic Atypical Femoral Fracture With Concomitant Hip and Knee Arthroplasties: A Case Report.

CASE: We present a case of an incomplete periprosthetic femoral fracture at the mid-distal third of the femoral stem after 11 months of bisphosphonate use. It is 1 of 4 cases of mid-distal periprosthetic atypical femoral fractures (PAFFs) found in our literature review. She was treated with protected weight-bearing, cessation of bisphosphonates, and teriparatide. Eighteen months after diagnosis, follow-up radiographs showed a bridging callus and reduction of a transverse fracture line. CONCLUSION: The incomplete PAFF was contributed by both decreased bone turnover from bisphosphonate use and increased mechanical stress at the lateral femoral cortex. Her previous left bipolar hemiarthroplasty and subsequent Total Knee Arthroplasty shifted the mechanical alignment medially, hence increasing tensile stress.

Predictors of 10-year Mortality After Hip Fracture Surgery in a Pre-Pandemic Cohort.

Introduction: Though hip fractures are associated with significant mortality and morbidity, increasing life expectancy in developed countries necessitates an analysis of mortality trends and factors predicting long term survival. The aim of this study is to identify the predictors of 10-year mortality as well as assess the correlation of Age-adjusted Charlson comorbidity index (ACCI) with 10-year mortality in a surgically treated Asian geriatric hip fracture population. Materials and Methods: From January 1, 2007 to December 31, 2009, 766 patients who underwent surgery for hip fracture with a minimum follow up of 10-years were recruited to the study (92% follow-up rate). A review of the patient's electronic hospital records was performed to glean the following data: patient demographics, pre-existing comorbidities, operation duration, length of stay, fracture configuration, as well as mortality data up to 10 years. CCI scores and individual co-morbidities were correlated with inpatient, 30-day, 1-year, 5-year and beyond 10-year mortality. Results: Of the 766 patients, the mortality rate for 30-day, 1-year, 5-year and 10-years was 2.9%, 12.0%, 38.9% and 61.6% respectively. The average ACCI was 5.31. The 10-year mortality for patients with ACCI ≤ 3, ACCI 4-5 and ACCI ≥ 6 are 29.4%, 57.4% and 77.5% respectively. End-Stage-Renal Failure (ESRF), liver failure and COPD were dominant predictors of mortality at 10 years, whereas cancer was the predominant predictor at 1 year. Discussion: ACCI significantly correlates with the 10-year mortality after surgically treated hip fractures with a shift of the dominant predictors from cancer to ESRF and COPD. This could inform future health policy and resource planning. This data also represents recently available pre-pandemic survival trends after hip fracture surgery and serves as a baseline for post-pandemic outcome surveillance of interventions for fragility fractures. Conclusion: This study demonstrates that ACCI correlated with 10-year mortality after surgical treatment of hip fractures.

Systems modelling as an approach for eliciting the mechanisms for hip fracture recovery among older adults in a participatory stakeholder engagement setting.

Introduction: Due to an aging population, the rising prevalence and incidence of hip fractures and the associated health and economic burden present a challenge to healthcare systems worldwide. Studies have shown that a complex interplay of physiological, psychological, and social factors often affects the recovery trajectories of older adults with hip fractures, often complicating the recovery process. Methods: This research aims to actively engage stakeholders (including doctors, physiotherapists, hip fracture patients, and caregivers) using the systems modeling methodology of Group Model Building (GMB) to elicit the factors that promote or inhibit hip fracture recovery, incorporating a feedback perspective to inform system-wide interventions. Hip fracture stakeholder engagement was facilitated through the Group Model Building approach in a two-half-day workshop of 25 stakeholders. This approach combined different techniques to develop a comprehensive qualitative whole-system view model of the factors that promote or inhibit hip fracture recovery. Results: A conceptual, qualitative model of the dynamics of hip fracture recovery was developed that draws on stakeholders' personal experiences through a moderated interaction. Stakeholders identified four domains (i.e., expectation formation, rehabilitation, affordability/availability, and resilience building) that play a significant role in the hip fracture recovery journey.. Discussion: The insight that recovery of loss of function due to hip fracture is attributed to (a) the recognition of a gap between pre-fracture physical function and current physical function; and (b) the marshaling of psychological resilience to respond promptly to a physical functional loss via uptake of rehabilitation services is supported by findings and has several policy implications.

End stage renal disease patients undergoing hip fracture surgery have increased length of stay, acute hospital bill size, and reduced survivorship-implications on a bundled care program.

End stage renal disease (ESRD) is an independent risk factor for the development of hip fractures and is associated with a higher mortality and complication rates. As these patients significantly skew healthcare financing in a bundled care payment (BCP) program, a risk stratified approach to BCPs could be done to take into account the difference in resources required. INTRODUCTION: End stage renal disease (ESRD) is an independent risk factor for the development of hip fractures and is associated with a higher mortality and complication rate. Hip fracture patients with ESRD may significantly skew healthcare financing in a bundled care payment (BCP) program. MATERIALS AND METHODS: ESRD patients undergoing hip fracture surgery from June 2007 to June 2012 within a tertiary hospital in Singapore were identified and matched to two other controls without ESRD based on secondary features of sex, age, fracture type, and surgery performed. Data was collected for American Society of Anesthesiologist (ASA) score, duration of surgery (DOS), length of stay (LOS), 30-day and 1-year mortality, and the presence of 10 other comorbidities: diabetes mellitus (DM), hypertension (HTN), hyperlipidemia (HLD), ischemic heart disease (IHD), arrhythmia (ARR), cerebrovascular disease (CVA), dementia (DEM), asthma (ASTH), peripheral vascular disease (PVD), and anemia (ANE) from electronic medical records. Costs were retrieved from the gross acute hospitalization bill. RESULTS: Forty-one ESRD patients were successfully matched with 82 controls. Patients with ESRD had higher ASA scores (3 vs 2, p = 0.0001), had 75% higher LOS (21 vs 12 days, p < 0.0001), were associated with 67% higher healthcare expenditure (median $20542 vs $12236, p < 0.0001), and 1-year mortality (OR: 19.6, p < 0.0001). ESRD patients had an average of 4.1 comorbidities per patient compared to 1.84 in the control group. CONCLUSION: ESRD is an outsized factor on the outcome of hip fracture patients who have markedly higher and more variable healthcare utilization.

Bony Anatomy around the Watershed Line of the Distal Radius.

Background An important surgical landmark in the distal radius is the watershed line. The watershed line is a landmark for the positioning of volar locking plates (VLP) in the distal radius. Inconsistencies remain in the literature as to the presence and dimensions of landmarks in this compact area. We studied the detailed anatomy and dimensions of the distal radius with reference to bony anatomy around the watershed line, with special attention to the area between the pronator quadratus (PQ) and radial styloid. Materials and Methods The distal radius regions of 31 cadavers (23 right sided and 8 left sided) were dissected and studied. The heights at the junction of the scaphoid and lunate fossa, at the radial styloid, at the midpoint in between, and the widths of the PQ line, scaphoid, and lunate fossa were measured. The angle subtended by the pronator fossa and the radial styloid was also recorded. Results The mean heights at the junction of the scaphoid and lunate fossa, radial styloid, and midpoint in between were 5.1, 15.7, and 8.2 mm, respectively. The widths of the PQ line, scaphoid, and lunate fossa were 27, 19.4, and 10.6 mm, respectively. The mean angulation between the pronator fossa and the radial styloid was 128.9 degrees. Conclusion The area between the PQ and watershed line comprises a narrow area of bone which tapers to a point at its medial extent largely below the lunate fossa, thus it can hardly contain any implant proximal to the lunate fossa. The anterior orientation of this area and the concave anatomy of the articular surface mean careful screw direction is imperative to avoid inadvertent joint penetration. An angulation exists between the pronator fossa and the radial styloid, below the scaphoid fossa.

Studies of the criteria for determining optimal location of medial patellofemoral ligament attachment sites.

Identifying appropriate attachment sites is important in the planning of medial patellofemoral ligament (MPFL) reconstruction. Two criteria are advanced to describe normal MPFL function, namely isometric criterion and desired pattern criterion. Subsequently, computational methods have applied these criteria to determine optimal attachment sites. So far, there is no study that compares the outcomes of these two criteria. For five subjects' 3D models of the patella and femur, three patellar sites and many femoral sites were identified as pairs of candidate attachment sites. For each patellar site, the criteria were applied to identify the matching femoral sites that satisfy them. The matching femoral site with the smallest length change was identified as the optimal femoral site. The desired pattern criterion finds fewer matching sites compared to the isometric criterion. In contrast, the isometric criterion can always find matching sites. The optimal femoral sites obtained vary significantly across different subjects. For most subjects, the optimal sites obtained using the isometric criterion are closer to known anatomical sites than those obtained using the desired pattern criterion. This study reaffirms that MPFL reconstruction is subject specific. The isometric criterion may be more reliable than the desired pattern criterion for determining optimal attachment sites. Graphical Abstract. Highlight of the paper. The location of the patella site significantly affects the location of the optimal femoral site. The isometric criterion option 1, with length at 0° regarded as MPFL's natural length, may be more reliable than other criteria or options for the planning of MPFL surgery because the optimal sites that it finds are closest to known anatomical sites.ᅟ.

Preoperative hypoalbuminemia: Poor functional outcomes and quality of life after hip fracture surgery.

AIMS: Hip fracture patients have severe deterioration of their quality of life and function after their injury. Markers of malnutrition such as low albumin and low body mass index (BMI) have been shown to increase mortality and complication rates but their effect on recovery of quality of life and function after hip fracture surgery is unclear. The main aim of this paper is to further investigate if low albumin affects recovery after hip fracture surgery, while additionally studying low BMI as a possible risk factor for poor recovery. PATIENTS AND METHODS: Retrospective analysis of 971 patients who underwent surgery for fragility hip fractures between January 2012 and December 2016 was performed. Demographic data, preoperative serum albumin and haemoglobin levels, BMI, Charlson Comorbidity Index (CCI), type of surgery (fixation vs replacement) and site of surgery were obtained. Patients were assessed using the Parker Mobility Scale (PMS), Harris Hip Score(HHS), Medical Outcomes Study 36-item Short-Form Health Survey (SF36) at pre-fracture, 6 weeks and 6 months after surgery. HHS was not available pre-operatively. Patients were grouped according to their albumin levels (low ≤35 g/L or normal) and BMI (underweight <18.5 or normal). Univariate and multivariate analyses were performed to examine the association between albumin and BMI and 6-month scores. RESULTS: On univariate analysis, patients with low albumin ≤35 g/L had lower baseline PMS and SF36 Physical Functioning (PF) score. On multivariate analysis, preoperative hypoalbuminemia was associated with lower 6-month HHS, PMS and SF36 PF scores even after accounting for baseline scores and other confounders. BMI had no effect on 6-month scores. CONCLUSION: Low albumin (≤35 g/L) is prevalent in elderly hip fracture patients and is associated with slower recovery of function and quality of life after surgery. Low albumin can be a useful prognostic tool to identify patients with poor recovery for further intervention or rehabilitation after hip fracture surgery.

Isolated Synovial Osteochondromatosis in a Completely Enclosed Suprapatellar Pouch: A Rare Case Report.

INTRODUCTION: A complete suprapatellar plica of the knee is a rare condition that separates the suprapatellar pouch from the rest of the knee cavity. Synovial osteochondromatosis is a rare benign monoarticular arthropathy affecting synovial joints that are clinically manifested as intra-articular multiple loose bodies. Isolated synovial osteochondromatosis within a concealed suprapatellar pouch caused by complete suprapatellar plica is an exceptionally rare occurrence. There is no well-documented report in literature on the diagnosis and arthroscopic approach to osteochondromatosis within a separated suprapatellar pouch. CASE REPORT: We report the case of a 61-year-old man who presented with a 3-month history of atraumatic right knee pain localized to the suprapatellar region. Pre-operative magnetic resonance imaging confirmed the presence of loose bodies at the suprapatellar region behind the complete septum. Loose bodies were concealed in a sealed suprapatellar pouch and could not be detected by routine arthroscopic examination of the knee cavity. The suprapatellar plica was punctured and loose bodies trapped within the enclosed suprapatellar compartment were arthroscopically removed. Histological examination of the loose bodies confirmed the diagnosis of osteochondromatosis. The patient postoperatively experienced complete relief of knee pain. CONCLUSION: Successful arthroscopic removal of loose bodies in the separated suprapatellar compartment requires careful study of pre-operative imaging and can effectively be performed throughthe standard anteromedial and anterolateral arthroscopic portals.

From "business continuity" to "back to business" for orthopaedic surgeons during the COVID-19 pandemic.

The coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented challenges to healthcare systems worldwide. Orthopaedic departments have adopted business continuity models and guidelines for essential and non-essential surgeries to preserve hospital resources as well as protect patients and staff. These guidelines broadly encompass reduction of ambulatory care with a move towards telemedicine, redeployment of orthopaedic surgeons/residents to the frontline battle against COVID-19, continuation of education and research through web-based means, and cancellation of non-essential elective procedures. However, if containment of COVID-19 community spread is achieved, resumption of elective orthopaedic procedures and transition plans to return to normalcy must be considered for orthopaedic departments. The COVID-19 pandemic also presents a moral dilemma to the orthopaedic surgeon considering elective procedures. What is the best treatment for our patients and how does the fear of COVID-19 influence the risk-benefit discussion during a pandemic? Surgeons must deliberate the fine balance between elective surgery for a patient's wellbeing versus risks to the operating team and utilization of precious hospital resources. Attrition of healthcare workers or Orthopaedic surgeons from restarting elective procedures prematurely or in an unsafe manner may render us ill-equipped to handle the second wave of infections. This highlights the need to develop effective screening protocols or preoperative COVID-19 testing before elective procedures in high-risk, elderly individuals with comorbidities. Alternatively, high-risk individuals should be postponed until the risk of nosocomial COVID-19 infection is minimal. In addition, given the higher mortality and perioperative morbidity of patients with COVID-19 undergoing surgery, the decision to operate must be carefully deliberated. As we ramp-up elective services and get "back to business" as orthopaedic surgeons, we have to be constantly mindful to proceed in a cautious and calibrated fashion, delivering the best care, while maintaining utmost vigilance to prevent the resurgence of COVID-19 during this critical transition period. Cite this article: Bone Joint Open 2020;1-6:222-228.

Ensuring Business Continuity of Musculoskeletal Care During the COVID-19 Pandemic: Experience of a Tertiary Orthopaedic Surgery Department in Singapore.

On February 8, 2020, Singapore raised its Disease Outbreak Response System Condition (DORSCON) level to Orange, indicating that coronavirus 2019 (COVID-19) was a severe disease with high human transmissibility. Using lessons learned from the severe acute respiratory syndrome (SARS) outbreak in 2003, the orthopaedic surgery department at Singapore General Hospital, a tertiary-level referral center, was prepared to handle this pandemic through business-continuity planning. The business that we are referring to is the "business" of orthopaedic surgery, encompassing clinical care, education, research, and administration. There is a lack of literature detailing business-continuity plans of surgical departments during pandemics, with new guidelines being developed. A large proportion of orthopaedic work, such as cases of fracture and infection, cannot be postponed. Even elective surgeries cannot be postponed indefinitely as it could result in detriment to the quality of life of patients. The aim of this article is to detail the business-continuity plans at our institution that allowed the delivery of essential musculoskeletal care through personnel segregation measures during the COVID-19 pandemic. Strategies to ensure the provision of timely medical intelligence, the reduction of nonessential ambulatory visits and surgical procedures, ensuring the safety and morale of staff, and continuing education and research efforts were paramount. As the COVID-19 pandemic unfolds, our posture needs to constantly evolve to meet new challenges that may come our way. Our existing business-continuity plan is not perfect and may not be applicable to smaller hospitals. There is conflict between envisioned normalcy, remaining economically viable as an orthopaedic department, and fulfilling training requirements, and educating the next generation of orthopaedic surgeons on the one hand and the need for segregation, workload reduction, virtual education, and social distancing on the other. Orthopaedic surgeons need to strike a balance between business continuity and adopting sustainable precautions against COVID-19. We hope that our experience will aid other orthopaedic surgery departments in adapting to this new norm, protecting their staff and patients, managing staff morale, and allowing the continuation of musculoskeletal care during the COVID-19 pandemic.

Serum albumin level predicts survival after surgical treatment of metastatic femur fractures: a retrospective study.

BACKGROUND: Surgical treatment for metastatic pathological femur fractures is associated with high mortality. Correct estimation of prognosis helps in determining the palliative value of surgical treatment and informs surgical decision. This study evaluates the risk factors for mortality in these patients who were surgically treated. METHODS: This is a retrospective study of 112 patients with surgical treatment of metastatic pathological femur fractures. Risk factors evaluated included age, ASA status, Charlson comorbidity index, preoperative serum albumin and haemoglobin, primary tumour site, presence of visceral metastases, presence of spinal metastases, time from diagnosis of cancer to occurrence of pathological fracture, type of surgical procedure performed, lesion and whether treatment was received for an actual or impending fracture. A Cox regression model was used to determine if these factors were independent significant factors for survival. RESULTS: Mortality at 2 years after surgical treatment of metastatic femoral fractures was 86%. Cox regression analysis of risk factors revealed that preoperative serum albumin and type primary tumour were independent risk factors for mortality. Presence of visceral metastases was strongly correlated to serum albumin levels. CONCLUSION: Preoperative serum albumin level and primary tumour site are independent risk factors of survival in patients treated for pathological femur fractures. Serum albumin level may be used as a prognostic tool to guide treatment in this cohort of patients with high mortality rates.