Incidence and Mortality Rate of Hip Fractures in Different Age Groups during the First Wave of the COVID-19 Pandemic.

BACKGROUND: The coronavirus disease-2019 (COVID-19) pandemic had enormous impact on many aspects of our society, including huge medical, social, and economic challenges. OBJECTIVES: To evaluate the impact of the first wave of the COVID-19 pandemic and the related movement restrictions on the incidence of hip fractures in different age groups. METHODS: This single center retrospective observational study included all patients over 60 years old admitted to our hospital with the diagnosis of hip fracture during March and April 2020. Exclusion criteria were periprosthetic or pathologic fractures and multitrauma. We collected the same data on all patients with hip fractures admitted during March and April of 2018 and 2019. RESULTS: Mean patient age increased from 81.7 to 85.0 years. Only two of 49 patients tested positive for COVID-19. The data show a decrease of 38% in fracture load, but a striking decrease of 85% and 59% among sexagenarians and septuagenarian, respectively. There was no decrease among nonagenarians. Early mortality, both at 30 days and 90 days, was twice as common during the pandemic. However, stratification by age group demonstrated that the risks of early mortality were the same as previous years. Mean waiting time for surgery decreased from 27.5 to 18.9 hours. Patient discharge to home over a rehabilitation facility increased from 9% to 17. CONCLUSIONS: The COVID-19 pandemic affected the epidemiology of hip fractures in the elderly. The incidence of fractures and age distribution were significantly different from other years. Discharge destinations were also affected. The management of hip fracture patients was not compromised.

[CAN HIP FRACTURE PATTERN OR TYPE OF SURGERY PREDICT ONE-YEAR MORTALITY OR MOBILITY?]

BACKGROUND: Several demographic and medical factors have an established effect on mortality and function after hip fractures, however varying fracture characteristics and surgical factors have been less thoroughly investigated. The study assessed the impact of specific fracture patterns on mortality and mobility one year post hip fracture. Other surgical factors including the type of intervention, major complications and sequential fractures were assessed as well. METHODS: An institutional hip fracture registry was reviewed. Mobility status scores were calculated one year post-operatively. RESULTS: Thirty days mortality was 4.6% and one year mortality was 19.9%. There was no significant effect of fracture type on mortality. However, patients receiving hemiarthroplasty had a significantly higher mortality (28.1%) than other patients receiving internal fixation (18.6%) or total hip arthroplasty (4%). An increased mobility status after intra-capsular fractures over extracapsular fractures was demonstrated. Patients receiving total hip arthroplasty had significantly better mobility at one year than patients with fracture fixation or hemiarthroplasty. Major complications and sequential fractures had no significant effect on outcome. CONCLUSIONS: Critical factors that influence decision making for orthopedic surgeons are revealed to have a lesser effect on the patient's ultimate outcome.

Acetabular cup orientation and postoperative leg length discrepancy in patients undergoing elective total hip arthroplasty via a direct anterior and anterolateral approaches.

BACKGROUND: Total hip arthroplasty (THA) is considered a successful surgical procedure. It can be performed by several surgical approaches. Although the posterior and anterolateral approaches are the most common, there has been increased interest in the direct anterior approach. The goal of the present study is to compare postoperative leg length discrepancy and acetabular cup orientation among patients who underwent total hip arthroplasty through a direct anterior (DAA) and anterolateral (ALA) approaches. METHODS: The study included 172 patients undergoing an elective THA by a single surgeon at our institution within the study period. Ninety-eight arthroplasties were performed through the ALA and 74 arthroplasties through the DAA. Preoperative planning was performed for all patients. Assessment of the two groups included the following postoperative parameters: abduction angle, cup anteversion angle and leg length discrepancy (LLD). Additional analysis was done to evaluate component positioning by comparing deviation from the Lewinnek zone of safety in both approaches. RESULTS: For the DAA the absolute LLD was 11 mm, ranging from -6 mm to 5 mm. For the ALA, the absolute LLD was 36 mm, ranging from -22 mm to 14 mm. None of the DAA patients had an absolute LLD greater than 6 mm. Comparatively, 7.4% of the ALA group exceeded 6 mm of LLD in addition to 2.1% with LLD greater than 10 mm. 15% of the ALA group resided out of the Lewinnek abduction zone compared to 3% of the DAA group (P = 0.016). 17% of the ALA group were out of the Lewinnek anteversion zone as opposed to 8% of the DAA group (P = 0.094). CONCLUSION: Our study demonstrates good component positioning outcomes and LLD values in patients following THA through the DAA compared to the ALA.

Recurrent rotator cuff tear: is ultrasound imaging reliable?

BACKGROUND AND HYPOTHESIS: The diagnostic workup of the painful shoulder after rotator cuff repair (RCR) can be quite challenging. The aim of this study was to assess the reliability of ultrasonography (US) for the detection of recurrent rotator cuff tears in patients with shoulder pain after RCR. We hypothesized that US for the diagnosis of recurrent rotator cuff tear after RCR would not prove to be reliable when compared with surgical arthroscopic confirmation (gold standard). METHODS: In this cohort study (diagnosis), we retrospectively analyzed the data of 39 patients with shoulder pain after arthroscopic RCR who had subsequently undergone US, followed by revision arthroscopy. The rotator cuff was evaluated first using US for the presence of retears. Thereafter, revision arthroscopy was performed, and the diagnosis was either established or disproved. The sensitivity and specificity of US were assessed in reference to revision arthroscopy (gold standard). RESULTS: A rotator cuff retear was indicated by US in 21 patients (54%) and by revision arthroscopy in 26 patients (67%). US showed a sensitivity of 80.8% and specificity of 100% in the diagnosis of rotator cuff retears. Omission of partial rotator cuff retears resulted in a spike in sensitivity to 94.7%, with 100% specificity remaining. CONCLUSION: US imaging is a highly sensitive and specific test for the detection of recurrent rotator cuff tears, as confirmed by revision arthroscopy, in patients with a painful shoulder after primary RCR.

Mortality and Function after Hip Fractures in Different Ethnic Populations in Israel.

BACKGROUND: Mortality and decrease in function after hip fracture are significantly related to patient factors including age, gender, co-morbidities, and mental status. Several studies demonstrated ethnic disparities in incidence, mortality, and functional outcome after hip fractures in the United States. OBJECTIVES: To assess the relationship between ethnicity and hip fracture incidence and outcomes of mortality, functional change, and perioperative complications in the Israeli population. METHODS: We reviewed our institutional hip fracture registry for all patients from 2014-2015. Patients with incomplete data, < 60 years of age, or pathologic and periprosthetic fractures were excluded. Our study comprised 693 patients. Ethnicity was based on country of birth. Specifically, for those born in Israel, the nationality of either Jewish or Arab was further dichotomized. Perioperative complications, mortality, and mobility status at 1 year follow-up were recorded. The ethnicities of 27,130 patients admitted to the medicine and surgical wards during the same time interval served as a control group for the hip fracture cohort. RESULTS: Immigrants from Europe and America had the highest incidence of hip fractures. Fracture types varied in incidence in groups with 70% of extracapsular hip fractures occurring in Arabs and immigrants from Eastern countries, compared to 60% in immigrants from Western countries and the former Soviet Union. Mortality, perioperative complications, and mobility at 1 year were similar in all ethnic groups. CONCLUSIONS: Our study demonstrated significant differences in incidence and fracture characteristic among ethnicities, but no difference in patient outcome. These findings differed from the available North American studies.

The medial border of the tibial tuberosity as an auxiliary tool for tibial component rotational alignment during total knee arthroplasty (TKA).

PURPOSE: The objective of this study was to quantify the amount of ensuing internal rotation of the tibial component when positioned along the medial border of the tibial tubercle, thus establishing a reproducible intraoperative reference for tibial component rotational alignment during total knee arthroplasty (TKA). METHODS: The angle formed from the tibial geometric centre to the intersection of both lines from the middle of the tibial tuberosity and its medial border was measured in 50 patients. The geometric centre was determined on an axial CT slice at 10 mm below the lateral tibial plateau and transposed to a slice at the level of the most prominent part of the tibial tuberosity. Similar measurements were taken in 25 patients after TKA, in order to simulate the intraoperative appearance of the tibia after making its proximal resection. RESULTS: This angle was found to be similar (n.s.) in normal and post-TKA tibiae [median 20.4° (range 15°-24°) vs. 20.7° (range 16°-25°), respectively]. In 89.3 % of the patients, the angle ranged from 17° to 24°. No statistical difference (p n.s.) was found between women and men in both normal [median -20.7° (range 16°-25°) vs. 19.9° (range 15°-24°)] and post-TKA tibiae [median 21.4° (range 19°-24°) vs. 20° (range 16°-25°)]. CONCLUSION: This study found that in 90 % of the patients, the medial border of the tibial tuberosity is internally rotated 17°-24° in relation to the line connecting the middle of the tuberosity to the tibial geometric centre. Since this anatomical landmark may be more easily identifiable intraoperatively than the commonly used "medial 1/3", it can provide a better quantitative reference point and help surgeons achieve a more accurate tibial implant rotational position. LEVEL OF EVIDENCE: Cohort and case control studies, Level III.

Radiographic templating of total hip arthroplasty for femoral neck fractures.

PURPOSE: The purpose of this study was to evaluate the use of pre-operative digital templating to minimize complications including limb length discrepancy (LLD), intraoperative fractures and early dislocations in patients with intracapsular femoral neck fractures. METHODS: We retrospectively compared 23 patients undergoing total hip arthroplasty (THA) for intracapsular femoral fractures with pre-operative digital templating and 48 patients without templating. RESULTS: The mean post-operative LLD was significantly lower in patients who had pre-operative templating than in the control group (6.7 vs. 11.5 mm, p = 0.023). Only three patients (13 %) with templating had LLD greater than 1.5 cm, compared to the 15 patients (31 %) without templating (p = 0.17). In eight cases the final femoral stem size matched the templated size, while 19 patients were within two size increments. Complications included one dislocation and one intra-operative fracture in the control group. CONCLUSION: The present study demonstrated that careful pre-operative planning may reduce LLD in patients undergoing THA due to intracapsular hip fractures.

Partial lateral patellar facetectomy as an alternative to lateral release in Total Knee Arthroplasty (TKA).

This study presents the selective use of partial patellar lateral facetectomy for maltracking during primary TKA, as an alternative to lateral release. Twenty three partial facetectomies were performed out of 191 TKAs (12%). Balanced tracking was achieved in 22 knees. At follow-up 2 patients had persistent anterior knee pain. Mean Knee Society score (KSS) was 94 and mean functional KSS was 86. Mean patellar score was 28. Patellar tilt angles were within 2 degrees in all but one knee. Patellar translation was within 2 mm in all cases. No complications were recorded. A control group of 46 matched patients had similar functional and radiographic results. If tracking is not satisfactory at the conclusion of TKA, our method of choice would be partial lateral facetectomy.

Dislocation after the first and multiple revision total hip arthroplasty: comparison between acetabulum-only, femur-only and both component revision hip arthroplasty.

BACKGROUND: Dislocation may complicate revision total hip arthroplasty (THA). We examined the correlation between the components revised during hip arthroplasty (femur only, acetabulum only and both components) to the rates of dislocation in the first and multiple revision THA. METHODS: We obtained data from consecutive revision THAs performed between January 1982 and December 2005. Patients were grouped into femur-only revision, acetabulum-only revision and revision THA for both components. RESULTS: A total of 749 revision THAs performed during the study period met our inclusion criteria: 369 first-time revisions and 380 repeated revisions. Dislocation rates in patients undergoing first-time revisions (5.69%) were significantly lower than in those undergoing repeated revisions (10.47%; p = 0.022). Within the group of first-time revisions, dislocation rates for acetabulum-only revisions (10.28%) were significantly higher than those for both components (4.61%) and femur-only (0%) reconstructions (p = 0.025). CONCLUSION: Although patients undergoing first-time revisions had lower rates of dislocations than those undergoing repeated revisions, acetabulum-only reconstructions performed at first-time revision arthroplasty entailed an increased risk for instability.

CONTEXTE: Il arrive que la dislocation vienne compliquer la révision des prothèses totales de la hanche (PTH). Nous avons analysé la corrélation entre les éléments révisés durant une arthroplastie de la hanche (fémur seulement, acétabulum seulement ou les 2 éléments) et le taux de dislocation qui accompagne une première ou de multiples révisions de PTH. MÉTHODES: Nous avons obtenu les données sur les révisions de PTH consécutives effectuées entre janvier 1982 et décembre 2005. Les patients ont été regroupés selon que la révision de leur PTH concernait le fémur seulement, l'acétabulum seulement ou les 2 éléments. RÉSULTATS: En tout, 749 révisions de PTH effectuées au cours de la période de l'étude répondaient à nos critères d'inclusion : 369 premières révisions et 380 révisions additionnelles. Les taux de dislocation ont été significativement moins élevés chez les patients soumis à une première révision (5,69 %) que chez les patients qui n'en étaient pas à leur première révision (10,47 %; p = 0,022). Dans le groupe soumis à une première révision, les taux de dislocation consécutive à une révision concernant uniquement l'acétabulum (10,28 %) ont été significativement plus élevés que dans les groupes qui ont subi des reconstructions des 2 éléments (4,61 %) ou du fémur seulement (0 %, p = 0,025). CONCLUSION: Même si les patients soumis à une première révision ont présenté des taux moindres de dislocation que ceux qui n'en étaient pas à leur première révision, les premières révisions d'arthroplastie impliquant une reconstruction de l'acétabulum seulement ont comporté un risque plus grand d'instabilité.

Effect of Surgical Safety checklist implementation on the occurrence of postoperative complications in orthopedic patients.

BACKGROUND: Surgical adverse events are errors that emerge during perioperative patient care. The World Health Organization recently published "Guidelines for Safe Surgery." OBJECTIVES: To estimate the effect of implementation of a safety checklist in an orthopedic surgical department. METHODS: We conducted a single-center cross-sectional study to compare the incidence of complications prior to and following implementation of the Guidelines for Safe Surgery checklist. The medical records of all consecutive adult patients admitted to the orthopedics department at Wolfson Medical Center during the period 1 July 2008 to 1 January 2009 (control group) and from 1 January 2009 to 1 July 2009 (study group) were reviewed. The occurrences of all complications were compared between the two groups. RESULTS: The records of 760 patients (380 in each group) hospitalized during this 12 month period were analyzed. Postoperative fever occurred in 5.3% versus 10.6% of patients with and without the checklist respectively (P = 0.008). Significantly more patients received only postoperative prophylactic antibiotics rather than both pre-and postoperative antibiotic treatment prior to implementation of the checklist (3.2% versus 0%, P = 0.004). In addition, a statistically non-significant 34% decrease in the rate of surgical wound infection was also detected in the checklist group. In a logistic regression model of postoperative fever, the checklist emerged as a significant independent predictor of this outcome: odds ratio 0.53, 95% confidence interval 0.29-0.96, P = 0.037. CONCLUSION: A significant reduction in postoperative fever after the implementation of the surgical safety checklist occurred. It is possible that the improved usage of preoperative prophylactic antibiotics may explain the reduction in postoperative fever.

Evolving trends in hip fracture patterns among the elderly from 2001 to 2022.

INTRODUCTION: Hip fractures among the elderly exhibit diverse patterns. Differences regarding treatment and prognosis of displaced versus undisplaced intracapsular fractures are well established. Unstable extracapsular fractures are associated with considerably higher rates of complications than stable fractures, including cutout failures, non-unions, wound complications and hardware related problems. The purpose of this study was to identify trends in the distribution of various types of hip fractures and their complexity between 2001 and 2022. METHODS: This retrospective study compared hip fractures treated in the years 2001, 2006, 2010, 2014, 2018, and 2022, excluding patients under 60 years old and those with pathological or peri­prosthetic fractures. Radiographs were reviewed and fracture patterns were categorized as stable extracapsular, unstable extracapsular, subtrochanteric or intracapsular. RESULTS: Out of 2646 patients admitted with proximal femoral fractures during these years, 2277 patients (69.5 % women) were available for analysis. Over the initial decade, the mean patient age gradually increased from 80 to 82, subsequently stabilizing. Gender distribution remained consistent, and the proportion of intracapsular fractures showed minimal variation (36-38 %). The most significant finding was the marked decrease in the proportion of stable-to-unstable extracapsular fractures during the first decade from 51 % to 31 %, followed by stabilization after 2010. Subgroup analysis by age revealed that while the proportion change between stable and unstable fractures remained insignificant in younger age groups (p = 0.41 for sexagenarians and 0.12 for septuagenarians), a significant change was observed in older patients (p = 0.002 for octogenarians and 0.04 for nonagenarians and older patients). DISCUSSION: This study reveals a surge in unstable peritrochanteric fractures between 2001 and 2010, particularly pronounced in patients over 80. This trend plateaued in the following decade, aligning with the stabilization of the cohort's mean age at 82. Numerous factors, from bone morphology to systemic markers, influence hip fracture types. Evolutions in osteoporosis screening and treatment over the last three decades may have contributed to the observed shifts in fracture pattern distribution. CONCLUSION: Understanding these trends enriches treatment strategies and underscores the need for further exploration of the interplay between demographic and anatomical factors in the etiology of specific fracture patterns.

Acetabular alignment and primary arc of motion for minus, skirtless, and skirted 28-, 32-, 36-, and 40-mm femoral heads.

We examined the influence of acetabular cup alignment on the primary arc of motion (PAOM) for minus (-3.5), skirtless (+3.5), and skirted (+10.5) neck lengths with 28-, 32-, 36-, and 40-mm femoral heads. Total hip arthroplasty was performed in a pelvic saw bone model. The acetabulum was positioned in 30°/45°/60° abduction and 0°/15°/30° anteversion, respectively. The PAOM was determined using a digital inclinometer for each of the acetabular positions and 12 femoral heads mentioned above. Best PAOM was found in 45° abduction and 15° to 30° anteversion as well as 60° abduction and 0° anteversion. Combinations of excessive abduction and anteversion as well as horizontalization and retroversion resulted in the worst PAOM. Primary arc of motion is mainly determined by cup alignment even when using larger femoral heads.

Precise technique for simple and accurate pip arthrodesis using a blunt KW technique.

Proximal interphalangeal joint (PIP) arthrodesis is a very common procedure in the practice of foot and ankle surgeons. The standard technique recommends using a Kirschner wire (KW) with double sharp ends. Using this technique there are some complication that can be eliminated by small modification. The technique of proximal interphalangeal joint arthrodesis using a simple blunt KW on one side with an accurate placement and avoidance of metatarsophalangeal joint (MTPJ) penetration without the need for fluoroscopy is described. This technique is simple, reproducible, very economical and avoiding most of the complications attributed to the KW.

Dislocation and infection after revision total hip arthroplasty: comparison between the first and multiply revised total hip arthroplasty.

Dislocation and infection are common complications of total hip arthroplasty (THA). This study evaluated the correlation between the number of revision THAs and the incidence of these complications. Data were obtained from 749 revision THAs. Average follow-up was 13.2 ± 5.9 years. Patients were grouped as first, second, third, and fourth or greater revision THA. Dislocation rates (5.68%, 7.69%, 8.33%, and 27.45%) and infection rates (1.35%, 1.92%, 2.5%, and 7.84%) in the first, second, third, and fourth or greater groups, respectively, correlated directly with the revision number and were highest (P < .001) in the fourth or greater group. Dislocation and infection are exponentially correlated with the number of revision THA. From the fourth revision onward, those risks are multiplied.

Total knee arthroplasty after failed distal femoral varus osteotomy using selectively stemmed posterior stabilized components.

The purpose of this study was to evaluate the outcomes of patients treated with total knee arthroplasty (TKA) for progression of arthritis after distal femoral varus osteotomy. Twenty-two consecutive distal femoral varus osteotomies converted to TKA were reviewed at a mean follow-up of 5 years (range, 2-14 years). Stemmed femoral or tibial components were used in 5 knees with poor bone quality, while the remaining 17 knees were treated with unstemmed components. The mean Knee Society knee and function scores in surviving knees were 91 points (range, 67-100 points) and 64 points (range, 50-70 points) respectively at final follow-up. Two patients underwent revision arthroplasty for polyethylene wear and component loosening at 8 and 11 years after the index arthroplasty, respectively. Standard components provide satisfactory stability in TKA after distal femoral varus osteotomy after appropriate ligamentous balancing, without the need for stemmed or highly constrained components in the majority of patients.

The long modified extended sliding trochanteric osteotomy.

The modified extended trochanteric osteotomy (ETO) preserves the posterior capsule and short external rotators through a lateral approach to the hip. The purpose of this study was to assess the performance of long ETOs, measuring 18 cm and above. Fifty three long ETOs were reviewed. The mean length of the osteotomy was 20.0 cm (range, 18-26). Mean scratch-fit length was 6.5 cm. Average follow-up was 57 months (range, 14-114 months). The Harris hip score improved from 37 preoperatively to 73 at last follow-up. Subsidence occurred in 12 (22.6%) cases. Eleven stems stabilised over the first year. One stem (1.9%) was revised for subsidence and loosening, one for a periprosthetic fracture and one for a fractured stem. Two (3.8%) cups had postoperative dislocations. Fifty two (98.1%) osteotomies united well. This series shows a low failure rate, with revision and union rates comparable to those reported for shorter ETOs. Performing the osteotomy through a lateral approach to the hip will enhance posterior stability.

Total hip arthroplasty in patients with Down's syndrome.

Patients with Down's syndrome (DS) have an increased incidence of coxarthrosis which may become symptomatic with prolonged life expectancy. We present seven consecutive patients (nine hips) with DS who had primary total hip arthroplasty (THA). Average clinical and radiological follow-up was 9.9 ± 6.4 years (range 2-22.25). Harris hip scores (HHS) improved significantly (p < 0.01) from 41.1 (range 18.5-65) to 80.2 (range 67.5-91) at latest follow-up. Two patients required revision arthroplasty for stem loosening at 16 (osteolysis) and six years (trauma) following THA, respectively. Six of the THAs required a constrained liner. No dislocations or deep infections were encountered. We contend that THA is a reliable surgical intervention in patients with DS and may be performed in symptomatic patients.

Trochanteric slide osteotomy on previously osteotomized greater trochanters.

UNLABELLED: The sliding trochanteric osteotomy is a useful and safe technique facilitating exposure of the hip in a complex arthroplasty. The modified sliding trochanteric osteotomy preserves the posterior capsule and short external rotators, allows anterior dislocation of the hip, and is associated with a lower dislocation rate. With the increased incidence of failed THAs and need for revision, there is an increased need for better exposure of challenging hips. Therefore, trochanteric osteotomies in hips that previously had osteotomies are not uncommon and likely will become frequent in the future. We evaluated use of the modified trochanteric slide osteotomy on greater trochanters that previously had osteotomies and were healed. We reviewed 38 patients with repeated osteotomies and 38 matched control patients with osteotomies on greater trochanters that did not have previous osteotomies. The minimum followup was 13 months (mean, 37 months; range, 13-73 months). Thirty-three osteotomies (87%) healed with bony union, four (11%) had fibrous union, and one (3%) had nonunion. Two (5%) patients had a new onset abductor lurch develop. Two (5%) patients had persistent trochanteric pain and two (5%) had dislocations. The bony union, fibrous union, and nonunion rates, and the abductor lurch, persistent trochanteric pain, and dislocation rates, were similar to those of the control patients. Repeated osteotomy on a previously healed greater trochanter osteotomy is a reliable procedure with similar clinical outcome and complication rates as a primary osteotomy. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Salvage of failed acetabular cages by nonbuttressed trabecular metal cups.

UNLABELLED: Acetabular revision of failed cages or rings may be facilitated by previously placed bone graft, enabling the use of highly porous cementless hemispheric cups. We retrospectively reviewed all 15 patients who had conversion of failed antiprotrusion cages (10 patients) or roof rings (five patients) to cementless cups. All patients had restoration of bone stock (three major column, eight morselized, four combined bone grafts) performed in conjunction with their index cage or ring reconstruction arthroplasty. The minimum followup was 24 months (average, 48.3 months; range, 24-72 months). Failure was defined as radiographic cup migration. In 12 of the 15 patients, there was no radiographic change in cup position at the last followup or symptoms indicative of loosening. The average Harris hip scores improved from 31 (range, 15-48) to 69 (range, 56-87) at latest followup. Cup failure occurred in three patients. In two patients, the failed cups were revised; the third patient refused additional surgery. Our experience suggests treatment of failed cages by highly porous cementless cups is a reasonable option. However, we recommend patients be followed closely to detect cup migration, which can occur until satisfactory bony ingrowth occurs. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.