The incidence and risk factors for abnormal postoperative blood tests following primary total joint replacement.

Aims: We aim to evaluate the usefulness of postoperative blood tests by investigating the incidence of abnormal results following total joint replacement (TJR), as well as identifying preoperative risk factors for abnormal blood test results postoperatively, especially pertaining to anaemia and acute kidney injury (AKI). Methods: This is a retrospective cohort study of patients who had elective TJR between January and December 2019 at a tertiary centre. Data gathered included age at time of surgery, sex, BMI, American Society of Anesthesiologists (ASA) grade, preoperative and postoperative laboratory test results, haemoglobin (Hgb), white blood count (WBC), haematocrit (Hct), platelets (Plts), sodium (Na+), potassium (K+), creatinine (Cr), estimated glomerular filtration rate (eGFR), and Ferritin (ug/l). Abnormal blood tests, AKI, electrolyte imbalance, anaemia, transfusion, reoperation, and readmission within one year were reported. Results: The study included 2,721 patients with a mean age of 69 years, of whom 1,266 (46.6%) were male. Abnormal postoperative bloods were identified in 444 (16.3%) patients. We identified age (≥ 65 years), female sex, and ASA grade ≥ III as risk factors for developing abnormal postoperative blood tests. Preoperative haemoglobin (≤ 127 g/dl) and packed cell volume (≤ 0.395 l/l) were noted to be significant risk factors for postoperative anaemia, and potassium (≤ 3.7 mmol/l) was noted to be a significant risk factor for AKI. Conclusion: The costs outweigh the benefits of ordering routine postoperative blood tests in TJR patients. Clinicians should risk-stratify their patients and have a lower threshold for ordering blood tests in patients with abnormal preoperative haemoglobin (≤ 127 g/l), blood loss > 300 ml, chronic kidney disease, ASA grade ≥ III, and clinical concern.

Trochleoplasty for severe trochlear dysplasia significantly improves the quality of life of patients with symptomatic patellar instability.

BACKGROUND: Trochleoplasty is a recognized surgical technique to address severe trochlear dysplasia. The clinical and radiological outcomes of trochleoplasty surgery in trochlear dysplasia have been well reported. There is a paucity in literature regarding the correlation between trochleoplasty and quality of life (QoL). The aim of this study is to measure the improvement in QoL, in patients with severe trochlear dysplasia and recurrent patellar instability following trochleoplasty. METHODS: Between 2013 and 2019, 51 trochleoplasty cases were performed in 48 patients. They were identified from our prospectively kept database. All operations were performed by a fellowship trained consultant sports knee surgeon. Functional outcomes and QoL scores were assessed using Kujala, IKDC and EQ-5D index. Objective outcomes were obtained following each patient's latest follow-up assessment. RESULTS: The mean age at operation was 22y (SD ± 4.7, range 14-37y) and the mean follow-up period was 21.6 months (SD ± 15.2, range 12-60 months). The mean Kujala score improved from 58.1 (SD 14.9) to 77.9 (SD 17.3) at latest follow-up (p < 0.001). The mean IKDC score improved from 40.5 (SD 14.2) to 69.5 (SD 22.8) at latest follow up (p < 0.001). The mean EQ-5D index also improved from 0.593 (SD 0.257) to 0.824 (SD 0.189) at latest follow-up (p = 0.003). A higher Body Mass Index (BMI; >30 kg/m2) was associated with inferior outcomes. CONCLUSION: Trochleoplasty is an effective surgical technique which improves the QoL in patients suffering from patellar instability secondary to severe trochlear dysplasia. BMI can be used to predict post-operative outcomes.

Joint replacement surgery for elbow tumours: a systematic review of outcomes.

BACKGROUND: Tumour resection followed by joint reconstruction is a surgical option in the appropriate patient. The evidence for such reconstructive surgery of the elbow joint is limited. The aim of this study is to review the literature to evaluate the outcomes of joint replacement surgery in tumours of the elbow. METHODS: A systematic review of PUBMED and EMBASE databases was conducted. Case series and comparative studies reporting results after total elbow arthroplasty, modular endo-prosthetic replacement and custom prosthesis were eligible for inclusion. RESULTS: Eleven eligible studies were identified (n = 134). At mean follow-up of 44 months, the overall revision rate was 14% and complication rate was 28%. The mean Mayo Elbow Performance Score was 75, with 56% of patients reporting good or excellent outcomes. The mean post-operative range of motion was 97°. DISCUSSION: Elbow prosthesis reconstruction after tumour resection can provide good functional outcomes at mid-term follow-up. The complication and revision rates are comparable to other indications for elbow replacement surgery. Further prospective studies are required to compare outcomes between different elbow arthroplasty options after tumour resection.

The effect of COVID-19 pandemic on the care of fragility hip fracture patients in the United Kingdom. A case control study in a major trauma centre.

INTRODUCTION: Coronavirus disease 2019 is a pandemic that forced a transformation in the services provided by the National Health Service in the United Kingdom. Fragility hip fractures account for over 65,000 cases per year in the elderly population. The study aims to assess the impact of the pandemic on fragility hip fractures. METHODS: A retrospective data gather was performed to identify fragility hip fractures from the 23rd of March 2020 to the 13th of May 2020, and from the 23rd of March 2019 to the 13th of May 19. Two groups were formed and compared over their 30 day follow up. RESULTS: The control group comprised of 97 patients, with a mean age of 82.1 years old (62-102 years) and M:F ratio of 38:59. The case group comprised of 102 patients, with a mean age of 82.3 years old (60-100 years) and a M:F ratio of 16:86. Significant differences between groups were identified for gender (p < 0.001), time to theatre (p = 0.002), length of stay (p < 0.001) and COVID-19 status (p = 0.001). In the Case group, association with mortality was found for male gender (p = 0.041), right side (p = 0.031) and COVID-19 positive test results (p = 0.011). CONCLUSION: Early surgical intervention is advocated wherever possible, and sufficient optimisation, prior to surgery whenever a COVID-19 positive patient is identified. A safe rehabilitation environment is paramount for recovery in this group of patients. Further studies are required to understand the effect of this pandemic on the fragility hip fractures. LEVEL OF EVIDENCE: Level III: Retrospective case-control study.

Pelvic and acetabular fracture management in intravenous drug users.

INTRODUCTION: Pelvic and acetabular fractures are significant injuries associated with high morbidity or mortality. Intravenous drug users (IVDU) represent a challenging group of patients, with an increased risk of complications and infection. To our knowledge there has not been any published literature concerning IVDU and this type of injuries. PATIENTS AND METHODS: A group of 19 patients with a history of IVDU and who had sustained an injury were identified. RESULTS: The mean age at injury was 36 years old; nine had a pelvic fracture and ten had an acetabular fracture. No complications were observed in the pelvic group. In the acetabular group, the infection risk was 50% and the risk of femoral head avascular necrosis was 33%. The mean follow up was 43.1 months from injury. CONCLUSION: We advise emphasis in the high infection and avascular necrosis rates, when consenting the patient for an operation. Furthermore, non-operative treatment should be considered, where possible. LEVEL OF EVIDENCE: Level III. Retrospective cohort study. Prognostic-investigating the effect of a patient characteristic on the outcome of the disease.

Can locking plate fixation of symphyseal disruptions allow early weight bearing?

INTRODUCTION: Anterior pubic symphyseal plate fixation is the recommended treatment for disruption of pubic symphysis in an unstable pelvic ring injury. The rigid construct offered by locking symphyseal plate has the theoretical advantage of allowing patients to weight bear early. However, there are concerns of catastrophic failure about the locked plate construct. The purpose of the study was to establish if locking plate fixation for pubic symphysis disruption was effective to allow patients to mobilise weight bearing immediately after surgery. PATIENT AND METHODS: Retrospective analysis of a prospectively collected database from a single centre was performed. The study period was from 2008 to 2017. Radiographic evidence of fixation failure, revision surgery, removal of metalwork and follow up duration was noted. RESULTS: We identified 46 patients (F:M 8:38) with a mean age of 46 years (range 14 to 74 years). Based on the mechanism of injury patients were classified into Antero-posterior compression (28), Vertical shear [10], lateral compression [4] and combined mechanism [4]. Either a 4-hole or 6-hole locking plate was used in all patients, depending on fracture extension. Posterior fixation was required in 28 (61%) patients. All patients were allowed to fully or partial weight bear. The mean radiological follow-up period was 31 weeks with 13 (28%) patients having evidence of radiological failure. Revision was performed in 1 (2%) patient, in whom the screws had pulled out of the bone. The most common mode of failure was either the screw backing out from the plate or broken screw. Among the 4 (8%) patients who had their metalwork removed, 1 (2%) had delayed onset of infection, 2 (4%) had symptoms related to backed out screw and 1 (2%) opted electively to have metalwork removed. CONCLUSIONS: With our series of patients, we have found that using locking plate for pubic symphyseal diastasis is safe and effective in allowing patients to weight bear early. A low complication rate and need for re-operation is demonstrated.

Evaluating risk factors following surgery for periprosthetic fractures around hip and knee arthroplasties.

BACKGROUND: The increasing demand for arthroplasty has resulted in an inevitable rise in the number of periprosthetic fractures around implants. Survival factors looking into patient's comorbidities and how they influence outcome are rare. This study aims to identify correlations between survival post-injury and pre-existing comorbidities. METHODS: A total of 144 patients underwent operative treatment for either a hip or a knee periprosthetic fracture from January 2008 to August 2017 at our Major Trauma Hospital. The mean age at injury was 80.9 years old (SD 9.9). Each patient had a case-based analysis to ascertain injury characteristics, operative parameters and comorbidities. RESULTS: The mean survival was 12.7 months (95% CI 8.4-17.1). Survival analysis showed a correlation between age more than 75 years old (p = 0.001), ASA grade of 3 or higher (p = 0.009 Breslow's test), history of CVA or TIA (p = 0.038 Breslow's test), dementia (p = 0.002 log rank test), depression (p = 0.013 log rank test) and gender (p = 0.041, Breslow's test) and survival post-periprosthetic fracture. Survival within the first year following injury was found to be affected by the presence of osteoporosis (p = 0.020) and dementia (p = 0.002). CONCLUSION: Periprosthetic fractures are associated with a high mortality risk (34.7%). Operative risks can be minimised with careful optimisation and surgical planning. ASA, age and comorbidities (dementia, CVA or TIA, osteoporosis) have a significant correlation with survival post-injury. Hence, careful patient selection for operative treatment is advised.