Appropriateness of the post-operative rehabilitation of low energy hip fractures in elderly in comparison with the AAOS appropriate use criteria at a level one trauma center.

PURPOSE: This study aimed to assess the appropriateness of the post-operative rehabilitation of low energy hip fractures in the elderly by comparing between the rehabilitations actually provided at level one trauma center and the AAOS Appropriate Use Criteria (AUC) recommendations. METHODS: A retrospective review of the medical charts of all patients who underwent surgery for hip fractures followed by post-operative rehabilitation between October 2016 and May 2018. The age, gender, fracture types, four AUC variables including; the surgical approach, pre-operative mobility/functional status, cognitive impairment, and post-operative delirium, and types of post-operative rehabilitation received were collected. The four patient variables were entered into the AUC application to generate the recommended rehabilitation procedures. Afterward, the rate of appropriateness of the treatments and the agreement between the rehabilitations actually provided and the AUC recommendation were measured. RESULTS: Over the study period, a consecutive series of 101 patients were included. The mean age was 75 years. Most of the patients were males (51.5%). Seventeen scenarios were observed in our patients. The most common scenario were patients with low functional/physical demands (48%), intact cognitive function (91%), non-arthroplasty approach (76%), and no post-operative delirium(97%). The overall appropriateness rate of the provided rehabilitation treatments for our patients in comparison with AUC recommendation was appropriate in 356 (48.7%) (P = .001), maybe appropriate in 19 (3%) (P < .001), rarely appropriate in 61 (8.3%) (P = .59), and 40% of rehabilitation procedures were not provided (P < .001). The actual treatment was appropriate and in agreement with the AUC recommendations in (100%) of three procedures (Deep venous thrombosis prophylaxis, pain management, and Inpatient Rehabilitation Facility or Skilled Nursing Facility), in (72.2%) of osteoporosis assessment/management, in (63.8%) of outpatient occupational/physical therapy, in (10.2%) of delirium prevention, in (33.3%) of delirium management and in (25%) of home care therapy. CONCLUSIONS: This study demonstrated that there is a remarkable variation in the appropriateness of the various post-operative rehabilitation procedures for elderly hip fracture. Additionally, the AUC application was easy to use and simple for identifying post-operative rehabilitation protocols for elderly hip fractures, hence, we recommend to use it in the trauma clinical practice. LEVEL OF EVIDENCE: IV.

Appropriateness of hip osteoarthritis management in clinical practice compared with the American Academy of Orthopaedic Surgeons (AAOS) criteria.

PURPOSE: The American Academy of Orthopaedic Surgeons (AAOS) developed the appropriate use criteria (AUC) for the management of hip osteoarthritis (OA) to guide surgeons in making decisions based on the best available evidence. This study aimed to assess the applicability of the AUC by comparing the actual treatment provided at our institution with the AUC recommendations. METHODS: A retrospective review of 115 patients who were diagnosed and treated for hip OA at our institution between December 2017 and December 2019 was performed. Data were collected and entered into the AUC application to determine the rate of appropriateness of the provided treatment according to the AUC recommendations. Then, the actual provided treatments were compared with the AUC recommendations to determine the agreement between the two. RESULTS: There were 115 patients, with a mean age of 50.08 years (range, 30-80 years). The most frequent patient characteristics were middle age (40-65 years) with function-limiting pain at moderate to long distances, minimal hip OA on X-ray examination, mild range of motion limitation, and presence of modifiable risk factors for negative outcomes. The overall rate of appropriateness and in agreement with the AUC recommendations was 100% for conservative treatments and 80.1% for surgical treatments. CONCLUSIONS: This study shows that the majority of the hip OA treatments provided at our institution were appropriate and in agreement with the AUC recommendations. Furthermore, the AUC can be easily accessed through a free web application using a computer or smartphone to obtain the recommended treatment for any patient with hip OA.

The outcome of hyperbaric oxygen therapy versus core decompression in the non-traumatic avascular necrosis of the femoral head: Retrospective Cohort Study.

BACKGROUND: Core decompression (CD) has been used in the treatment of pre-collapse stages avascular necrosis (AVN) with good results. Hyperbaric oygen therapy (HBO) was used as a non-invasive treatment for pre-collapse stages osteonecrosis with favorable results. This study aimed to compare the outcomes of HBO versus CD in stage II of non-traumatic AVN of the femoral head. METHODS: Data were collected retrospectively for patients with non-traumatic AVN of the femoral head that was confirmed by MRI and underwent HBO or CD between January 2010 and December 2018, with a minimum follow-up of 12 months. Oxford Hip Score (OHS), radiographic progression, and Short-Form 12(SF12) were used to assess the outcomes. RESULTS: Nineteen patients with 23 stage II AVN of the femoral head were included, 12 (52.2%) in CD, and 11 (47.8%) in the HBO group with an average follow-up of 34.2 ± 18.4 months.66.7% of patients in CD and 81.8% in the HBO group achieved satisfactory hip function outcome with statistically significant mean Oxford Hip Score (35.8 ± 6.7 and 35.5 ± 5.1) (P 0.009 & .003) respectively.No statistical difference of OHS and SF12 (PCS &MCS) was found between the two groups (P 0.202, 0.128 & .670 respectively).Eight (34.7%) cases progressed to a higher radiological stage at one year follow-up. The rate of progression was not statistically significant between both groups (P 0.469) with no statistical difference of OHS and SF12 (PCS & MCS) in the progressed group (P 0.747, 0.648 & 0.416) respectively. CONCLUSION: This study showed that the HBO is promising and as effective as CD in the treatment of non-traumatic pre-collapsed AVN of the femoral head. Hence, HBO could be used as an alternative non-invasive treatment option.

The role of patient positioning on the outcome of acetabular fractures fixation through the Kocher-Langenbeck approach.

BACKGROUND: Open reduction and internal fixation through the Kocher-Langenbeck approach is the treatment of choice for selected acetabular fracture patterns. Patient positioning (lateral vs prone) can affect the outcome and post-operative complications. METHODS: A retrospective cohort of seventy-three adult patients' with acetabular fractures treated with open reduction and internal fixation through the Kocher-Langenbeck approach in either prone or lateral position. Primary outcome was the quality of radiographic fracture reduction; secondary outcomes included operative time, intra-operative estimated blood loss and pre-operative complications. RESULTS: The demographics and fracture type were similar between the two groups. There was no difference in the quality of reduction using the Matta radiographic grading. Laterally positioned group demonstrated significant shorter surgical time and lower incidence of iatrogenic sciatic nerve injury. There was no difference in estimated blood loss, heterotopic ossification or infection. CONCLUSION: This study showed no difference in the quality of fracture reduction, intraoperative blood loss, post-operative infection and heterotopic ossification between both groups. Hence, patients' condition, surgeon experience and preference are important factors for deciding patient positioning in the Kocher-Langenbeck approach for acetabulum fracture fixation.

The Orthopedic Residency Program at Hamad Medical Corporation During COVID-19 Crisis: an Evolving Educational Strategy.

The COVID-19 pandemic has changed the strategies of most of the teaching hospitals worldwide, affecting the educational process in residency programs. The System Wide Incident Command Committee in the state of Qatar has set the country's medical response to the crisis. In line with command committee directives, the orthopedic surgery residency program planned an educational strategy keeping the trainees' wellbeing and education a priority and taking advantage of the pandemic as a tool of personal and professional growth.

External fixation for primary and definitive management of open long bone fractures: the Syrian war experience.

AIMS: To report on the experience of one field hospital in using external fixation as a primary and definitive treatment for open long bone fractures during the Syrian war. METHODS: A total of 955 patients with open long bone fractures (femur, tibia, humerus) who were operated and followed up at a field hospital in Aleppo, Syria, from 2011 to 2016, were retrospectively reviewed. Different types of uniplanar and some multiplanar external fixators were used solely as a primary and definitive tool until bone union was achieved. Union rate and infection rate were reported in association with age, gender, Gustilo/Anderson classification, type of fixator, and presence of neurovascular injuries. RESULTS: Out of 955 patients, 404 (42.3%) continued to follow up until bone union or until removal of the external fixator. The average age was 27.5 ± 11 years, with 91.6% males and 8.2% females. The overall union rate was 68.3% (276/404), with 60.9% (95/156) in open femur, 70.3% (137/195) in open tibia, and 83% (44/53) in open humerus fractures. The overall infection rate was 16.7% (67/401), with 18.6% in open femur, 18.1% in open tibia, and 5.8% in open humerus fractures. CONCLUSION: The use of external fixation for definitive treatment of open long bone shaft fractures caused by high energy trauma during times of wars or conflicts is reliable and should be used in early frontline intervention and in areas with limited access to resources.

Avulsion fracture of anterior inferior iliac spine complicated by hypertrophic malunion causing femoroacetabular impingement: Case report.

INTRODUCTION: Avulsion fractures of the anterior inferior iliac spine are uncommon and such injuries are caused by the sudden forceful contraction of the straight head of rectus femoris muscle while the hip is hyperextended and the knee is flexed. CASE PRESENTATION: This case report describes the condition of 17 year old male footballer who complained of pain in the right groin for duration of 2 years after being involved in forceful sport activity. Detailed history, clinical examination, X-rays and CT scan revealed hypertrophic malunion of avulsion fracture of anterior inferior iliac spine causing an extra-articular type of femoroacetabular impingement. The patient was surgically treated when conservative management was unsuccessful. DISCUSSION: This is the first case of hypertrophic malunion of avulsion fracture of anterior inferior iliac spine with femoroacetabular impingement that has been recognized in Qatar. The patient was surgically treated in order to relieve symptoms and avoid osteoarthritis. CONCLUSION: Malunited avulsion fracture of anterior inferior iliac spine can cause extra-articular femoroacetabular impingement.