The characteristics and predictors of mortality in periprosthetic fractures around the knee.

Aims: Periprosthetic fractures (PPFs) around the knee are challenging injuries. This study aims to describe the characteristics of knee PPFs and the impact of patient demographics, fracture types, and management modalities on in-hospital mortality. Methods: Using a multicentre study design, independent of registry data, we included adult patients sustaining a PPF around a knee arthroplasty between 1 January 2010 and 31 December 2019. Univariate, then multivariable, logistic regression analyses were performed to study the impact of patient, fracture, and treatment on mortality. Results: Out of a total of 1,667 patients in the PPF study database, 420 patients were included. The in-hospital mortality rate was 6.4%. Multivariable analyses suggested that American Society of Anesthesiologists (ASA) grade, history of peripheral vascular disease (PVD), history of rheumatic disease, fracture around a loose implant, and cerebrovascular accident (CVA) during hospital stay were each independently associated with mortality. Each point increase in ASA grade independently correlated with a four-fold greater mortality risk (odds ratio (OR) 4.1 (95% confidence interval (CI) 1.19 to 14.06); p = 0.026). Patients with PVD have a nine-fold increase in mortality risk (OR 9.1 (95% CI 1.25 to 66.47); p = 0.030) and patients with rheumatic disease have a 6.8-fold increase in mortality risk (OR 6.8 (95% CI 1.32 to 34.68); p = 0.022). Patients with a fracture around a loose implant (Unified Classification System (UCS) B2) have a 20-fold increase in mortality, compared to UCS A1 (OR 20.9 (95% CI 1.61 to 271.38); p = 0.020). Mode of management was not a significant predictor of mortality. Patients managed with revision arthroplasty had a significantly longer length of stay (median 16 days; p = 0.029) and higher rates of return to theatre, compared to patients treated nonoperatively or with fixation. Conclusion: The mortality rate in PPFs around the knee is similar to that for native distal femur and neck of femur fragility fractures. Patients with certain modifiable risk factors should be optimized. A national PPF database and standardized management guidelines are currently required to understand these complex injuries and to improve patient outcomes.

Predictors of mortality in periprosthetic fractures of the hip: Results from the national PPF study.

INTRODUCTION: Periprosthetic fractures (PPFs) around the hip joint are increasing in prevalence. In this collaborative study, we aimed to investigate the impact of patient demographics, fracture characteristics, and modes of management on in-hospital mortality of PPFs involving the hip. METHODS: Using a multi-centre cohort study design, we retrospectively identified adults presenting with a PPF around the hip over a 10-year period. Univariate and multivariable logistic regression analyses were performed to study the independent correlation between patient, fracture, and treatment factors on mortality. RESULTS: A total of 1,109 patients were included. The in-hospital mortality rate was 5.3%. Multivariable analyses suggested that age, male sex, abbreviated mental test score (AMTS), pneumonia, renal failure, history of peripheral vascular disease (PVD) and deep surgical site infection were each independently associated with mortality. Each yearly increase in age independently correlates with a 7% increase in mortality (OR 1.07, p=0.019). The odds of mortality was 2.99 times higher for patients diagnosed with pneumonia during their hospital stay [OR 2.99 (95% CI 1.07-8.37) p=0.037], and 7.25 times higher for patients that developed renal failure during their stay [OR 7.25 (95% CI 1.85-28.47) p=0.005]. Patients with history of PVD have a six-fold greater mortality risk (OR 6.06, p=0.003). Mode of treatment was not a significant predictor of mortality. CONCLUSION: The in-hospital mortality rate of PPFs around the hip exceeds 5%. The fracture subtype and mode of management are not independent predictors of mortality, while patient factors such as age, AMTS, history of PVD, pneumonia, and renal failure can independently predict mortality. Peri-operative optimisation of modifiable risk factors such as lung and kidney function in patients with PPFs around the hip during their hospital stay is of utmost importance.

Comparing the Results of Total Ankle Arthroplasty Vs Tibiotalar Fusion (Ankle Arthrodesis) in Patients with Ankle Osteoarthritis since 2006 to 2020- A Systematic Review.

Background: This study compares the outcomes of patients undergoing total ankle arthroplasty (TAA) and tibiotalar fusion (ankle arthrodesis) in patients with end-stage osteoarthritis. The primary outcome assessed was Patient Reported Outcome Measures (PROMS); secondary outcomes included the incidence of revision, re-operation, and complications. Methods: A systematic review of studies examining the outcomes of patients undergoing TAA and/or tibiotalar fusion from 2006 to 2020 was conducted. Individual cohort studies and randomized control trials were included. Outcomes were assessed at two and five years. Results: 21 studies were included: 16 arthroplasty (2,016 patients) and 5 arthrodesis (256 patients) studies. No significant difference in PROMS was evident two years post-surgery - American Orthopaedic Foot and Ankle Society (AOFAS) scores were 78.8 (95% CI-confidence interval: 76.6-80.8; n=1548) and 80.8 (95% CI: 80.1-81.5; n=206 patients) for the arthroplasty and arthrodesis groups respectively. Two years post-surgery the revision rates for the arthroplasty and arthrodesis groups were similar - 3.5% (n=9) and 3.7% (n=61) respectively (OR-odds ratio: 1.05; 95% CI: 0.51-2.13); however, the re-operation rate was 2.5 times higher for the arthroplasty group (12.2%) in comparison to the arthrodesis group (5.1%) (OR: 2.57; 95% CI: 1.43-4.62). Documented complications in the arthroplasty group were half those documented in the arthrodesis group two years post-surgery (OR: 0.53; 95% CI: 0.37-0.77). No arthrodesis studies were found which contained mean 5-year follow-up data within the study period. Conclusion: Despite recent developments in TAA design, we found no clear evidence as to their superiority over ankle arthrodesis when considering patient outcomes two years postoperatively. However, this conclusion could be debatable in some types of patients such as diabetic patients, posttraumatic patients and patients with stiff hindfoot and midfoot.

Preventing Venous Thromboembolism after elective total hip arthroplasty surgery - are the current guidelines appropriate? Venous thromboembolism prophylaxis in elective total hip arthroplasty surgery.

INTRODUCTION: Venous Thromboembolism after elective Total Hip Arthroplasty surgery is a well-recognised complication, resulting in fatal pulmonary embolism, post thrombotic syndrome and recurrent thrombotic episodes. Guidelines developed by clinical organisations attempt to provide evidence-based recommendations to clinicians. METHODS: This narrative review evaluated the current available literature in relation to the available guidelines, to evaluate whether the current major guidelines reflect the evidence base. All major clinical guidelines were collated through database searching, alongside the relevant clinical studies. PRINCIPAL FINDINGS: The promotion of a multi-modal approach, combining mechanical and chemical prophylaxis, does appear to be well validated, with mechanical prophylaxis offering positive clinical effects with little negative clinical consequence. Within the current guidelines surrounding VTE prevention in the elective-THA patient, there does appear to be a lack of prescription in relation to risk stratification and adopting personalised approaches for specific patient subsets. CONCLUSION: We suggest moving away from protocolisation of VTE prevention, given the evidence base is not fully developed to allow a 'one-size-fits-all' approach.