Incidence of dislocation and associated risk factors in patients with a femoral neck fracture operated with an uncemented hemiarthroplasty.

BACKGROUND: Several factors might be associated with risk of dislocating following uncemented hemiarthroplasty (HA) due to femoral neck fracture (FNF). Current evidence is limited with great variance in reported incidence of dislocation (1-15%). Aim of this study was to identify the cumulative incidence of first-time dislocation following HA and to identify the associated risk factors. METHOD: We performed a retrospective cohort study of patients receiving an HA (BFX Biomet stem, posterior approach) at Copenhagen University Hospital, Bispebjerg, in 2010-2016. Patients were followed until death or end of study (dec 2018). Dislocation was identified by code extraction from the Danish National Patient Registry. Variables included in the multivariate model were defined pre-analysis to include: age, sex and variables with a p-value < 0.1 in univariate analysis. A regression model was fitted for 90 days dislocation as the assumption of proportional hazard rate (HR) was not met here after. RESULTS: We identified 772 stems (some patients occurred with both right and left hip) and 58 stems suffered 90 dislocations during the observation period, resulting in a 7% (CI 5-9) incidence of dislocation 90 days after index surgery. 55 of the 58 stems (95%) experienced the first dislocation within 90 days after surgery. Only absence of dementia was identified as an independent protective factor in the cause-specific model (HR 0.46 (CI 0.23-0.89)) resulting in a 2.4-fold cumulative risk of experiencing a dislocation in case of dementia. Several other variables such as age, sex, various medical conditions, surgery delay and surgical experience were eliminated as statistical risk factors. We found a decrease in survival probability for patients who experienced a dislocation during follow-up. CONCLUSIONS: The incidence of first-time dislocation of HA (BFX Biomet stem, posterior approach) in patients with a hip fracture is found to be 7% 90 days after surgery. Due to the non-existing attribution bias, we claim it to be the true incidence. Dementia was among several variables identified as the only risk factor for dislocation. In perspective, we may consider treating patients with dementia by other methods than HA e.g., HA with cement or with a more constrained solution. Also, a surgical approach that reduce the risk of dislocation should be considered.

Good rate of satisfaction but suboptimal clinical outcome at long-term follow-up in a large series of patients who had operative stabilization of the deltoid ligament of the ankle.

PURPOSE: To report results following deltoid ligament reconstruction in a large series of patients. METHODS: For consecutive patients who had a medial ankle ligament stabilization 2010-2018 information from their medical files was registered, and they were invited for follow-up in 2021-2022. They answered questions about satisfaction with the treatment and current symptoms, and they completed the Foot and Ankle Measurement (FAAM) questionnaire. RESULTS: Of the 503 patients, 342 (68%) had a history of trauma to the ankle and 114 (23%) had previous ankle surgery. 67% had other procedures (besides synovectomy) simultaneous to medial ligament reconstruction. 269 patients (54%) responded to the invitation for follow-up. For 182 (71%) of the responders, the operation solved their ankle problems. 163 (63%) were satisfied with the surgery. 192 (71%) would repeat the operation. 173 (67%) had pain in the ankle during the past week, and 86 (50%) of these were not able to run. FAAM ADL-scores were significantly higher than in a mixed group of ankle/foot patients but not normal. CONCLUSION: The relatively high degree of satisfaction despite suboptimal clinical results may reflect the complex nature of the deltoid ligament insufficient ankle. It is concluded that repair or reconstruction of the deltoid ligament is only performed in patients reporting ankle instability and with peroperatively demonstrated medial instability and pathology to the ligament. LEVEL OF EVIDENCE: Level III.

Setting proficiency standards for simulation-based mastery learning of short antegrade femoral nail osteosynthesis: a multicenter study.

BACKGROUND AND PURPOSE: Orthopedic trainees frequently perform short antegrade femoral nail osteosynthesis of trochanteric fractures, but virtual reality simulation-based training (SBT) with haptic feedback has been unavailable. We explored a novel simulator, with the aim of gathering validity evidence for an embedded test and setting a credible pass/fail standard allowing trainees to practice to proficiency. PATIENTS AND METHODS: The research, conducted from May to September 2020 across 3 Danish simulation centers, utilized the Swemac TraumaVision simulator for short antegrade femoral nail osteosynthesis. The validation process adhered to Messick's framework, covering all 5 sources of validity evidence. Participants included novice groups, categorized by training to plateau (n = 14) or to mastery (n = 10), and experts (n = 9), focusing on their performance metrics and training duration. RESULTS: The novices in the plateau group and experts had hands-on training for 77 (95% confidence interval [CI] 59-95) and 52 (CI 36-69) minutes while the plateau test score, defined as the average of the last 4 scores, was 75% (CI 65-86) and 96% (CI 94-98) respectively. The pass/fail standard was established at the average expert plateau test score of 96%. All novices in the mastery group could meet this standard and interestingly without increased hands-on training time (65 [CI 46-84] minutes). CONCLUSION: Our study provides supporting validity evidence from all sources of Messick's framework for a simulation-based test in short antegrade nail osteosynthesis of intertrochanteric hip fracture and establishes a defensible pass/fail standard for mastery learning of SBT. Novices who practiced using mastery learning were able to reach the pre-defined pass/fail standard and outperformed novices without a set goal for external motivation.

A clinical guide to the medial ligaments of the ankle: Anatomy, function, diagnosis of injuries and treatment of instability-a narrative review.

BACKGROUND: The aim was to provide an update on anatomy and function of the medial ankle ligaments, diagnosis of their injuries and treatment of medial ankle instability. METHODS: Literature search on PubMed. RESULTS: Injuries to the deltoid ligament are not uncommon in relation to malleolar fractures and ankle sprains. Chronic instability may lead to ankle osteoarthritis. However, there is no consensus on diagnostic criteria (clinically, by imaging and by arthroscopy), on indications for non-operative and operative treatment, and on standards for repair and reconstruction of the ligament complex. There is no current evidence to support acute repair of deltoid ligament injury. Reports on the effect of isolated deltoid ligament reconstruction are very sparse. CONCLUSION: There is a need for a focused effort to establish evidence for all aspects of deltoid ligament injury.

Continuous Glucose Monitoring Reveals Perioperative Hypoglycemia in Most Patients With Diabetes Undergoing Major Surgery: A Prospective Cohort Study.

OBJECTIVE: To investigate the frequency and duration of hypo- and hyperglycemia, assessed by continuous glucose monitoring (CGM) during and after major surgery, in departments with implemented diabetes care protocols. SUMMARY BACKGROUND DATA: Inadequate glycemic control in the perioperative period is associated with serious adverse events, but monitoring currently relies on point blood glucose measurements, which may underreport glucose excursions. METHODS: Adult patients without (A) or with diabetes [non-insulin-treated type 2 (B), insulin-treated type 2 (C) or type 1 (D)] undergoing major surgery were monitored using CGM (Dexcom G6), with an electrochemical sensor in the interstitial fluid, during surgery and for up to 10 days postoperatively. Patients and health care staff were blinded to CGM values, and glucose management adhered to the standard diabetes care protocol. Thirty-day postoperative serious adverse events were recorded. The primary outcome was duration of hypoglycemia (glucose <70 mg/dL). Clinicaltrials.gov: NCT04473001. RESULTS: Seventy patients were included, with a median observation time of 4.0 days. CGM was recorded in median 96% of the observation time. The median daily duration of hypoglycemia was 2.5 minutes without significant difference between the 4 groups (A-D). Hypoglycemic events lasting ≥15 minutes occurred in 43% of all patients and 70% of patients with type 1 diabetes. Patients with type 1 diabetes spent a median of 40% of the monitoring time in the normoglycemic range 70 to 180 mg/dL and 27% in the hyperglycemic range >250 mg/dL. Duration of preceding hypo- and hyperglycemia tended to be longer in patients with serious adverse events, compared with patients without events, but these were exploratory analyses. CONCLUSIONS: Significant duration of both hypo- and hyperglycemia was detected in high proportions of patients, particularly in patients with diabetes, despite protocolized perioperative diabetes management.

Peripheral nerve-blocks and associations with length of stay and readmissions in fast-track total hip and knee arthroplasty.

BACKGROUND: Peripheral nerve blocks (PNB) have recently been recommended in total hip (THA) and knee (TKA) arthroplasty as they may reduce pain, morphine consumption, length of stay (LOS) and complications. However, whether PNBs are associated with early discharge within an enhanced recovery protocol including multimodal analgesia is uncertain. METHODS: An observational multicenter study from January to August 2017 in six Danish Arthroplasty Centers with established fast-track protocols. Prospective recording of preoperative characteristics and information on PNB, LOS and readmissions through the Danish National Patient Registry and medical records. Multiple logistic regression was used to investigate associations between PNB and a LOS >1 day, LOS >4 days, and 30-days readmissions. We also reported on mobilization, pain, opioid and fall-related complications leading to LOS >4 days or readmissions. RESULTS: A total of 2027 (58.6%) THA and 1432 (41.4%) TKAs with a median LOS of 1 day (IQR 1-2) and 5.3% (CI:4.6-6.1) 30-days readmission rate were identified. PNB was used in 40.7% (CI:38.2-43.3) of TKA and 2.7% (CI:2.0-3.5) of THA, but with considerable interdepartmental variation (0.0-89.0% for TKA). There was no association between PNB and LOS >1 day (OR:1.19 CI:0.82-1.72; p = .354), LOS >4 days (OR:1.4 CI:0.68-2.89; p = .359) or 30-days readmissions (OR:1.02 CI:0.63-1.65; p = .935) in TKA. Logistic regression in THA was not possible due to limited use of PNB. In TKA there were 12 (2.1% CI:1.2-3.6) with and 1 (0.1% CI:0.02-0.7) without a PNB, who had mobilization, pain or opioid-related complications, and 5 (0.9% CI:0.4-2.0) versus 4 (0.5% CI:0.2-1.2) who fell. Correspondingly, 2 (3.7% CI:1.0-12.6) and 11 (0.6% CI:0.3-1.0) of THA patients had these complications, while 0 (0.0% CI:0.0-6.6) and 17 (0.8% CI:0.5-1.3) fell. CONCLUSION: Routine use of peripheral nerve blocks was not associated with early discharge or 30-days readmissions in fast-track THA and TKA. Future studies should focus on benefits of PNB in high-risk patients.

Frailty and osteoporosis in patients with hip fractures under the age of 60-a prospective cohort of 218 individuals.

Research on younger patients with hip fractures is limited. This study adds knowledge on patient and injury characteristics, and DXA was investigated at the time of the fracture. Risk factors for osteoporosis and fractures were numerous among young patients, and osteoporosis was markedly more prevalent than in the general population. INTRODUCTION: Knowledge on younger patients with hip fractures is limited. Common preconceptions are that they suffer fractures due to high-energy trauma, alcohol or substance use disorder but not associated to osteoporosis. We aimed to descriptively analyze the characteristics of young and middle-aged patients with hip fractures and examine bone mineral density (BMD) by dual-energy x-ray absorptiometry (DXA) at the time of the fracture. METHODS: A prospective multicenter cohort study on adult patients with hip fractures below age 60 collected detailed information on patient characteristics regarding demographics, trauma mechanism, previous fractures, comorbidity and medication, and lifestyle factors. DXA results were compared to population-based reference data. RESULTS: The cohort contains 91 women and 127 men, median age 53 (IQR 47-57). Most fractures, 83%, occurred in patients aged 45-59. Two-thirds of all fractures resulted from low-energy trauma. Half of the patients had prior fractures after age 20. Thirty-four percent were healthy, 31% had one previous disease, and 35% had multiple comorbidities. Use of medication associated with increased fracture risk was 32%. Smoking was prevalent in 42%, harmful alcohol use reported by 29%, and signs of drug-related problems by 8%. Osteoporosis according to WHO criteria was found in 31%, osteopenia in 57%, and normal BMD in 12%. CONCLUSION: In patients with hip fractures below age 60, risk factors for osteoporosis and fractures were numerous. Moreover, the prevalence of osteoporosis was markedly higher than in the general population. We suggest that young and middle-aged patients with hip fractures undergo a thorough health investigation including DXA, regardless of trauma mechanism.

Risk of hospitalization and hip fracture associated with psychotropic polypharmacy in patients with dementia: A nationwide register-based study.

OBJECTIVE: To investigate the association of benzodiazepines and antidepressants on the risk of hospitalization and hip fracture in patients with dementia initiating antipsychotic drug treatment. METHODS: A register-based retrospective cohort study using data on all incident dementia cases (≥65 years) initiating antipsychotic treatment as monotherapy or in combination with benzodiazepines and/or antidepressants in Denmark from 2000 to 2015. The outcomes of interest were all-cause hospitalization and hip fracture. Cox proportional hazards models with adjustment for multiple variables were used to investigate risk of hospitalization and hip fracture within 180 days. RESULTS: The risk of all-cause hospitalization during 180-days follow-up was significantly increased by 55% (adjusted HR: 1.55, 95% CI: 1.29-1.86, p < 0.0001), when antipsychotic use was combined with benzodiazepines, when compared to antipsychotic monotherapy. The association between the combination of antipsychotics and benzodiazepines with the risk of hip fracture did not reach statistical significance (adjusted HR: 1.50, 95% CI: 0.99-2.26, p = 0.0534). CONCLUSIONS: The observed increased risk of all-cause hospitalization and hip fracture may indicate increased drug-related adverse events. Thus, careful and regular monitoring is needed to assess response to treatment and decrease the risk of adverse events, when antipsychotics are combined with BZDs, albeit confounding cannot be fully excluded within the current design.

A medical history of arterial thrombosis is a strong predictor of post-operative myocardial infarction and stroke in patients with hip fractures-a nationwide cohort study.

INTRODUCTION: Hip fractures lead to a substantial burden of disease and mortality among the elderly. Myocardial infarction (MI) and stroke are serious and overlooked complications, and their impact on mortality and morbidity may be underestimated. We investigated; 90-day absolute risk of stroke and MI following hip fracture surgery, and ii) anamnestic risk factors associated with elevated risk of postoperative MI and stroke. METHODS: All Danish patients aged ≥60 undergoing first time hip fracture surgery in 2000-2017 were identified. Outcomes were MI or stroke 90 days after surgery. We performed gender-stratified cumulative incidence functions and multivariate Cox regression models adjusted for age and comorbidities. RESULTS: 124,660 patients were included. Incidence of MI was 2.2% and 1.3%, and incidence of stroke was 3.5% and 2.5%, in men and women, respectively. The most important risk factor for MI and stroke was a previous event. Hazard ratio (HR) of MI associated with previous MI was 2.43 (95% Confidence Interval (CI) 2.02-2.92) in men and 2.65 (95% CI 2.23-3.16) in women, while the HR of stroke associated with previous stroke was 4.17 (95% CI 3.73-4.67) and 3.73 (95% CI 3.43-4.08), respectively. Other risk factors of MI were; sex, age, and a history of heart failure, hypertension, peripheral artery disease or diabetes. For postoperative stroke; sex age, and atrial fibrillation were important risk factors. CONCLUSION: MI and stroke after hip fractures are overlooked and serious complications. Persons with elevated risk can be identified at admission, based on their medical history.

Sex differences in incidence rate, and temporal changes in surgical management and adverse events after hip fracture surgery in Denmark 1997-2017: a register-based study of 153,058 hip fracture patients.

Background and purpose - Extensive research and national multidisciplinary programs have striven to introduce uniform standards of treatment and mitigate mortality and adverse events after hip fracture surgery over the past decades. A large-scale overview of temporal developments in hip fracture surgery and care is warranted.Patients and methods - We studied Danish patients aged ≥ 60 years, sustaining their first ever hip fracture between 1997 and 2017. Patients were identified from the Danish National Patient Registry (DNPR). Incidence rates of first hip fracture were calculated per 1,000 patient-years and stratified by age group and sex. Information on pre-injury living settings, comorbidities, and medications were obtained from national administrative registers. Type of fracture and treatment choice were recorded, and patients were followed for 1 year to observe mortality, readmission, and surgical complications.Results - Data from 153,058 patients was analyzed. Incidence rate decreased in both sexes, but only led to a reduction in the annual number of hip fractures in the female population. Choice of surgery shifted away from sliding hip screws and parallel implants (SHS-PI), towards intramedullary nailing and hemi-/arthroplasties for trochanteric and femoral neck fractures, respectively. Pre-injury diagnosed morbidity and 1-year readmissions increased contrary to mortality. Median age remained stable around 83 (IQR 77-88) for women and 80 (IQR 73-86) for men.Interpretation - Over the past 2 decades important aspects of hip fracture management have improved. However, sex differences were observed, and men remain more vulnerable than women in terms of morbidity, mortality, and incidence rate.

Introducing the "hip call" to facilitate early surgical treatment of hip fractures: A feasibility study.

INTRODUCTION: Surgical treatment of hip fractures within 24-48 hours decreases morbidity and mortality, but goals for early surgery have not been widely achieved so far. The primary aim of this study was to investigate the feasibility of implementation of a hip call, and the secondary aim was to investigate the effect of the hip call on time for pre-operative preparation and surgery compared to a historical control cohort. MATERIALS AND METHODS: From March 4, 2019 until June 30, 2019, admission of patients at Copenhagen University Hospital, Bispebjerg, Denmark, with a suspected hip fracture triggered an acute hip call. Key personnel are summoned to secure rapid pre-operative preparation and surgery. The implementation was defined feasible, if ≥ 75% of the patients were ready for surgery within 4 hours and had surgery initiated within 24 hours of hospital arrival. The historical control cohort was patients with hip fractures in the same period in 2018. RESULTS: A total of 128 patients were included in 2019, and 99 in 2018. After implementation of hip call, 83% of patients were ready for surgery within 4 hours. After vs before hip call, 88% vs 51% were operated within 24 hours and 96% vs 79% within 36 hours. Time from admission to surgery (hh:mm) was reduced by mean 10:33 (CI 07:46-13:20), P < .001. CONCLUSION: The implementation of a hip call was feasible with 83% of patients being ready for surgery within 4 hours, and 88% being operated within 24 hours. Future large-scale studies should clarify potential benefits on clinical outcome.

Risk of reoperation within 12 months following osteosynthesis of a displaced femoral neck fracture is linked mainly to initial fracture displacement while risk of death may be linked to bone quality: a cohort study from Danish Fracture Database.

Background and purpose - Most guidelines use patient age as a primary decision factor when choosing between osteosynthesis or arthroplasty in displaced femoral neck fractures. We evaluate reoperation and death risk within 1 year after osteosynthesis, and estimate the influence of age, sex, degree of displacement, and bone quality.Patients and methods - All surgeries for femoral neck fractures with parallel implants (2 or 3 screws or pins) performed between December 2011 and November 2015 were collected from the Danish Fracture Database. Radiographs were analyzed for initial displacement, quality of reduction, protrusion, and angulation of implants. The bone quality was estimated using the cortical thickness index (CTI). Garden I and II type fractures with posterior tilt < 20° were excluded.Results - 654 patients with a mean age of 69 years were included. 59% were female. 54% were Garden II with posterior tilt > 20° or Garden III, and 46% were Garden IV. Only 38% were adequately reduced. 19% underwent reoperation and 18% died within 12 months. Female sex, surgical delay between 12 and 24 hours vs. < 12 hours, Garden IV type fracture, inadequate reduction, and protrusion of an implant were associated with statistically significant increased reoperation risk. No significant association between reoperation and age, CTI, or the initial angulation of implants was found. Notably, CTI was linked inversely with death risk.Interpretation - Reoperation risk is linked mainly to primary displacement and reduction of the fracture, with no apparent effect of age or bone quality. Bone quality may be linked with risk of death.

Regaining pre-fracture basic mobility status after hip fracture and association with post-discharge mortality and readmission-a nationwide register study in Denmark.

BACKGROUND: early mobilization after hip fracture (HF) is an important predictor of outcome, but knowledge of the consequences of not achieving the pre-fracture basic mobility status in acute hospital recovery is sparse. OBJECTIVE: we examined whether the regain of pre-fracture basic mobility status evaluated with the cumulated ambulation score (CAS) at hospital discharge was associated with 30-day post-discharge mortality and readmission. DESIGN: this is a population-based cohort study. MEASURES: using the nationwide Danish Multidisciplinary HF Database from January 2015 through December 2015, 5,147 patients 65 years or older undergoing surgery for a first-time HF were included. The pre-fracture and discharge CAS score (0-6 points with six points indicating an independent basic mobility status) were recorded. CAS was dichotomized as regained or not and entered into adjusted Cox regression overall analysis and stratified by sex, age, body mass index, Charlson comorbidity index, type of fracture, residential status and length of acute hospital stay. Outcome measures were 30-day post-discharge mortality and readmission. RESULTS: overall mortality and readmission were 8.3% (n = 425) and 17.1% (n = 882), respectively. Mortality was 3.5% (n = 71) among patients who regained their pre-fracture CAS score compared with 11.4% (n = 354) among those who did not. Adjusted hazard ratios for 30-day mortality and readmission were 2.76 (95% confidence interval [CI] = 2.01-3.78) and 1.26 (95% CI = 1.07, 1.48), respectively, for patients who did not regain their pre-fracture CAS compared with those who did. CONCLUSIONS: we found that the loss of pre-fracture basic mobility level upon acute hospital discharge was associated with increased 30-day post-discharge mortality and readmission after a first time HF.

Hip-fracture osteosynthesis training: exploring learning curves and setting proficiency standards.

Background and purpose - Orthopedic surgeons must be able to perform internal fixation of proximal femoral fractures early in their career, but inexperienced trainees prolong surgery and cause increased reoperation rates. Simulation-based virtual reality (VR) training has been proposed to overcome the initial steep part of the learning curve but it is unknown how much simulation training is necessary before trainees can progress to supervised surgery on patients. We determined characteristics of learning curves for novices and experts and a pass/fail mastery-learning standard for junior trainees was established. Methods - 38 first-year residents and 8 consultants specialized in orthopedic trauma surgery performed cannulated screws, Hansson pins, and sliding hip screw on the Swemac TraumaVision VR simulator. A previously validated test was used. The participants repeated the procedures until they reached their learning plateau. Results - The novices and the experts reached their learning plateau after an average of 169 minutes (95% CI 152-87) and 143 minutes (CI 109-177), respectively. Highest achieved scores were 92% (CI 91-93) for novices and 96% (CI 94-97) for experts. Plateau score, defined as the average of the 4 last scores, was 85% (CI 82-87) and 92% (CI 89-96) for the novices and the experts, respectively. Interpretation - Training time to reach plateau varied widely and it is paramount that simulation-based training continues to a predefined standard instead of ending after a fixed number of attempts or amount of time. A score of 92% comparable to the experts' plateau score could be used as a mastery learning pass/fail standard.

Postoperative Treatment of Pain after Hip Fracture in Elderly Patients with Dementia.

BACKGROUND/AIMS: Prior studies have shown that patients with dementia are at risk of receiving insufficient treatment for pain after a hip fracture. We therefore hypothesized that elderly hip fracture patients with dementia received less postoperative pain treatment than those without dementia. METHOD: All patients (age ≥65 years) who had been operated on for a hip fracture in the Copenhagen University Hospital region in 2009 were included. Data about analgesic use for the first 72 h after surgery were acquired from the hospitals' electronic medication system and linked with information about dementia, comorbidity, and prior drug use. RESULTS: A total of 1,507 patients were included, of which 296 (19.6%) suffered from dementia. Both groups were equally likely to receive paracetamol and opioids. Patients with dementia received lower doses of oral morphine equivalents during the first [dementia vs. no dementia: 29.0 (26.4-31.8) vs. 34.7 (33.1-36.4) mg, p = 0.001] and second [27.8 (25.4-30.5) vs. 31.2 (29.9-32.4) mg, p = 0.019] but not on the third postoperative day (p = 0.10). CONCLUSION: The lower doses of opioids may reflect uncertainty about how to treat pain patients with dementia. Further guidance is needed, as inadequate treatment of pain may have adverse consequences.

Physical Activity in the Acute Ward Following Hip Fracture Surgery is Associated with Less Fear of Falling.

Early mobilization following hip fracture surgery reduces medical complications and mortality, but may increase the risk of falling. The aim was to objectively measure the physical activity (time spent upright) the first week after hip fracture surgery and relate it to functional performance and fear of falling at discharge. The 24-hr upright time was measured for a median of six days using a thigh-worn accelerometer in 37 patients (mean 80 years ± 8.4) and increased from median 13 (IQR 6-31) min to 46 (11-107) min at day 7. More upright time at discharge was associated with less fear of falling (r = -.48, p = .01, n = 27), which also was associated with fast gait speed (r = -.50, p = .02, n = 23) and a faster Timed Up and Go test time (r = .54, p < .01, n = 22), indicating a need for further studies on motivation and limitations for more physical activity following hip fracture surgery.

Fast-track pathway for reduction of dislocated hip arthroplasty reduces surgical delay and length of stay.

BACKGROUND AND PURPOSE: Dislocation is one of the most common complications following hip arthroplasty. Delay until reduction leads to pain for the patient, and may increase the risk of complications. We investigated the safety aspect of a fast-track pathway for dislocated hip arthroplasties and evaluated its effect on surgical delay and length of stay (LOS). PATIENTS AND METHODS: 402 consecutive and unselected dislocations (253 patients) were admitted at our institution between May 10, 2010 and September 31, 2013. The fast-track pathway for early reduction was introduced on January 9, 2011. Fast-track patients with a suspected dislocation (with no radiographic verification) were moved directly to the post-anesthesia care unit and then straight to the operating room. Dislocation was confirmed under fluoroscopy with reduction under general anesthesia. Surgical delay (in hours), LOS (in hours), perioperative complications, and complications during the hospital stay were recorded. Dislocation status for fast-track patients (confirmed or unconfirmed by fluoroscopy) was also recorded. RESULTS: Both surgical delay (2.5 h vs. 4.1 h; p < 0.001) and LOS (26 h vs. 31 h; p < 0.05) were less in patients admitted through the fast-track pathway than in patients on regular pathway. Perioperative complications (1.6% vs. 3.7%) and complications during the hospital stay (11% vs. 15%) were also less, but not statistically significantly so. Only 1 patient admitted through fast-track pathway had a fracture instead of a dislocation; all the other fast-track patients with suspected dislocation actually had dislocations. INTERPRETATION: The fast-track pathway for reduction of dislocated hip arthroplasty results in less surgical delay and in reduced LOS, without increasing perioperative complications or complications during the patient's stay.

Precision of radiostereometric analysis (RSA) of acetabular cup stability and polyethylene wear improved by adding tantalum beads to the liner.

BACKGROUND AND PURPOSE: In traditional radiostereometric analysis (RSA), 1 segment defines both the acetabular shell and the polyethylene liner. However, inserting beads into the polyethylene liner permits employment of the shell and liner as 2 separate segments, enabling distinct analysis of the precision of 3 measurement methods in determining femoral head penetration and shell migration. PATIENTS AND METHODS: The UmRSA program was used to analyze the double examinations of 51 hips to determine if there was a difference in using the shell-only segment, the liner-only segment, or the shell + liner segment to measure wear and acetabular cup stability. The standard deviation multiplied by the critical value (from a t distribution) established the precision of each method. RESULTS: Due to the imprecision of the automated edge detection, the shell-only method was least desirable. The shell + liner and liner-only methods had a precision of 0.115 mm and 0.086 mm, respectively, when measuring head penetration. For shell migration, the shell + liner had a precision of 0.108 mm, which was better than the precision of the shell-only method. In both the penetration and migration analyses, the shell + liner condition number was statistically significantly lower and the bead count was significantly higher than for the other methods. INTERPRETATION: Insertion of beads in the polyethylene improves the precision of femoral head penetration and shell migration measurements. A greater dispersion and number of beads when combining the liner with the shell generated more reliable results in both analyses, by engaging a larger portion of the radiograph.

Hip arthroscopy with labral repair for femoroacetabular impingement: short-term outcomes.

PURPOSE: The purpose of this study was to examine the progression of clinical outcomes 3, 6 and 12 months after hip arthroscopy with labral repair for femoroacetabular impingement (FAI). METHODS: From May 2009 to December 2011, 87 consecutive patients [55 females (median age 38, range 17-63) and 32 males (median age 38, range 15-59)] underwent hip arthroscopy and labral repair, by the same experienced surgeon. Standardised, but unstructured, post-operative rehabilitation instructions were provided. Function and pain were evaluated using modified Harris Hip Score (mHHS) and visual analogue scale (VAS) pre-operatively and post-operatively at 3, 6, and 12 months. RESULTS: A main effect of time was seen for mHHS and pain (VAS) at 3, 6, and 12 months (p < 0.001). Mean (SE) mHHS improved significantly from 59.9 (1.9) pre-operatively to 74.5 (1.9) after 3 months (p < 0.001), and again from 3 to 6 months from 74.5 (1.9) to 80.1 (1.9) (p = 0.004), with no additional changes from 6 to 12 months [80.1 (1.9)-78.7 (1.9), (n.s.)]. Also, the mean (SE) VAS improved significantly from pre-operative 57.9 (2.6) to 30.0 (2.6) after 3 months (p < 0.001), and from 30.0 (2.6) to 22.6 (2.6) (p = 0.017), after 6 months with no additional changes from 6 to 12 months [22.6 (2.6)-27.9 (2.6), (n.s.)]. CONCLUSIONS: Improvements in function (mHHS) and pain (VAS) were seen in patients after hip arthroscopy with labral repair for FAI at 3, 6, and 12 months. While significant improvements occurred from 3 to 6 months, no further improvements were seen from 6 to 12 months.

Virtual-reality simulation to assess performance in hip fracture surgery.

BACKGROUND AND PURPOSE: Internal fixation of hip fractures is a common and important procedure that orthopedic surgeons must master early in their career. Virtual-reality training could improve initial skills, and a simulation-based test would make it possible to ensure basic competency of junior surgeons before they proceed to supervised practice on patients. The aim of this study was to develop a reliable and valid test with credible pass/fail standards. METHODS: 20 physicians (10 untrained novices and 10 experienced orthopedic surgeons) each performed 3 internal fixation procedures of an undisplaced femoral neck fracture: 2 hook-pins, 2 screws, and a sliding hip screw. All procedures were preformed on a trauma simulator. Performance scores for each procedure were obtained from the predefined metrics of the simulator. The inter-case reliability of the simulator metrics was explored by calculation of intra-class correlation coefficient. Validity was explored by comparison between novices' and experts' scores using independent-samples t-test. A pass/fail standard was set by the contrasting-groups method and the consequences were explored. RESULTS: The percentage of maximum combined score (PM score) showed an inter-case reliability of 0.83 (95% CI: 0.65-0.93) between the 3 procedures. The mean PM score was 30% (CI: 7-53) for the novices and 76% (CI: 68-83) for the experienced surgeons. The pass/fail standard was set at 58%, resulting in none of the novices passing the test and a single experienced surgeon failing the test. INTERPRETATION: The simulation-based test was reliable and valid in our setting, and the pass/fail standard could discriminate between novices and experienced surgeons. Potentially, training and testing of future junior surgeons on a virtual-reality simulator could ensure basic competency before proceeding to supervised practice on patients.