Factors associated with failure of fixation of Vancouver B fractures around a cemented polished tapered stem: A 5 to 14 year follow up study.

AIMS: There is increasing evidence for fixation as opposed to revision for Vancouver B fractures around polished taper slip stems, however it is remains unclear whether fixation is associated with stem loosening in the longer term. This study aims to assess survival of plate-fixation of Vancouver-B-fractures around a polished-taper- slip cemented stem and identify factors associated with failure. METHODS: Retrospective cohort study assessed 129 consecutive unilateral Vancouver-B-fractures around cemented Exeter stems at a minimum of 5 years following open-reduction-internal-fixation (ORIF) with unilateral non-locked unilateral plating+/-cerclage cables. The primary outcome measure was reoperation for any reason. Kaplan Meier survival analysis was performed. RESULTS: Fractures (B1 n = 31 (24%); B2 n = 91 (71%); and B3 n = 7 (5%)) occurred at median of 6 years (IQR 1.2-9.2) after primary surgery. Mean patient age was 78.2 (SD10.56, range 46-96) and 54 (42.9%) were female. Mean follow up was 8.7 years (SD 2.48, 5.7 to 14.4). Symptomatic femoral stem loosening requiring revision occurred in two B2 fractures of metaphyseal split and short spiral patterns. The most common mode of failure was non-union (n = 7, 5%). Both fixation failure (n = 6/31 Vs n = 3/91 vs n = 0/7, p = 0.008) and reoperation (n = 8/31 vs n = 6/91 vs n = 0/7, p = 0.008) were significantly higher following fixation of B1 fractures compared to B2 and B3 fractures. Overall 5year survival free from reoperation was 88.8% (82.0-94.7 95%CI). B1 fracture types were associated with an increase risk of failure (endpoints fixation failure p = 0.010; and reoperation p = 0.016). Transverse fractures (B1) were associated with a relative risk of reoperation of 4.22 (1.63-10.9 95% CI, p = 0.008). CONCLUSION: Fixation of Vancouver-B fractures around cemented Exeter stems, when the bone-cement interface is intact and the fracture is anatomically reducible, had an excellent 5-year survival. Only 2 (1.6%) cases of late femoral stem loosening occurred, however, B1 type transverse fractures were associated with a higher rate of reoperation.

Intravenous Tranexamic Acid Given at Femoral Fragility Fracture Surgery Reduces Blood Transfusion Requirements Fourfold.

AIMS: This study aims to determine whether intraoperative intravenous (IV) tranexamic acid (TXA) affects blood loss following the surgical management of femoral fragility fractures (FFF). METHODS: This was a single centre (university teaching hospital) non-randomised case-control study. There were 361 consecutive patients with FFF admitted over a 4-month period were included (mean age 81.4yrs; mean BMI 23.5; 73.7% female). Patient demographics, comorbidities, preoperative anticoagulation use, surgical management, intravenous TXA use, perioperative haemoglobin (Hb) and haematocrit, and requirement for blood transfusion were recorded. The primary outcome was postoperative blood transfusion requirement. Secondary outcomes included postoperative day one calculated blood loss (CBL) (using the Nadler and Gross formulae) and fall in Hb (percentage) from preoperative levels; and the incidence of thrombotic events and mortality up to 30 days. RESULTS: Groups were well matched in terms of patient demographics, comorbidities, preoperative anticoagulation use, injury types and surgical management. Intravenous TXA 1 g given at the beginning of surgery at the discretion of the operating team: 178 (49%) received TXA and 183 (51%) did not. The requirement for postoperative blood transfusion was significantly less in the TXA group: 15/178 (8.4%) compared to 58/183 (31.7%) (p < 0.001; Chi square). TXA significantly reduced both the percentage fall in Hb (mean difference 4.3%, p < 0.001) and the CBL (mean difference -222 ml, p < 0.001). There was no difference in VTE (2 vs 1, p = 0.620) or other thrombotic events (2 vs 0, p = 0.244) between groups. CONCLUSION: 1 g of intraoperative intravenous TXA during the surgical management of FFF was associated with reduced rate of transfusion, CBL and the percentage drop in HB. The use of TXA in this study was not randomised, so there could be un-quantifiable bias in the patient selection.

Tibial shaft fractures - to monitor or not? a multi-centre 2 year comparative study assessing the diagnosis of compartment syndrome in patients with tibial diaphyseal fractures.

AIMS: The aim of this study was to compare the outcome in patients who did and did not undergo continuous compartment pressure monitoring (CCPM) following a tibial diaphyseal fracture. PATIENTS AND METHODS: We performed a retrospective cohort study of 287 patients with an acute tibial diaphyseal fractures who presented to three centres over a two-year period. Demographic data, diagnosis, management, wound closure, complications, and subsequent surgeries were recorded. The primary outcome measure was the rate of short-term complications. Secondary outcomes were time to fasciotomy and split-skin grafting rates. RESULTS: Of the 287 patients in the study cohort, 171 patients underwent CCPM (monitored group; MG) and 116 did not (non-monitored group; NMG). There were 21 patients who developed ACS and underwent fasciotomy, with comparable rates in both groups (n=13 in the MG vs n=8 in NMG; p=0.82). There was no difference in the rate of complications between groups (all p>0.05). The mean time from admission to fasciotomy was 22.1hrs, with a mean time of 19.8hrs in the MG and 25.8hrs in the NMG (mean difference, 6hrs; p=0.301). One patient in the NMG required a below-knee amputation. There was a trend towards a reduced requirement for split-skin grafting post decompression in the MG (15% vs 50%; p=0.14). CONCLUSION: This study found no difference in the short-term complication rates in those patients that underwent CCPM and those that did not following a fracture of the tibial diaphysis. CCPM does appear to be safe with no increase in the rate of fasciotomies performed. There was a trend towards a reduced time to fasciotomy and a reduced rate of split skin grafting for wound closure with CCPM. LEVEL OF EVIDENCE: Level III (Diagnostic: Retrospective cohort study).

Vancouver B periprosthetic fractures involving the Exeter cemented stem.

AIMS: The aim of this study was to determine whether fixation, as opposed to revision arthroplasty, can be safely used to treat reducible Vancouver B type fractures in association with a cemented collarless polished tapered femoral stem (the Exeter). METHODS: This retrospective cohort study assessed 152 operatively managed consecutive unilateral Vancouver B fractures involving Exeter stems; 130 were managed with open reduction and internal fixation (ORIF) and 22 with revision arthroplasty. Mean follow-up was 6.5 years (SD 2.6; 3.2 to 12.1). The primary outcome measure was revision of at least one component. Kaplan-Meier survival analysis was performed. Regression analysis was used to identify risk factors for revision following ORIF. Secondary outcomes included any reoperation, complications, blood transfusion, length of hospital stay, and mortality. RESULTS: Fractures (B1 n = 74 (49%); B2 n = 50 (33%); and B3 n = 28 (18%)) occurred at median of 4.2 years (interquartile range (IQR) 1.2 to 9.2) after primary total hip arthroplasty (THA) (n = 138) or hemiarthroplasty (n = 14). Rates of revision and reoperation were significantly higher following revision arthroplasty compared to ORIF for B2 (p = 0.001) and B3 fractures (p = 0.050). Five-year survival was significantly better following ORIF: 92% (95% confidence interval (CI) 86.4% to 97.4%) versus 63% (95% CI 41.7% to 83.3%), p < 0.001. ORIF was associated with reduced blood transfusion requirement and reoperations, but there were no differences in medical complications, hospital stay, or mortality between surgical groups. No independent predictors of revision following ORIF were identified: where the bone-cement interface was intact, fixation of B2 or B3 fractures was not associated with an increased risk of revision. CONCLUSION: When the bone-cement interface was intact and the fracture was anatomically reducible, all Vancouver B fractures around Exeter stems could be managed with fixation as opposed to revision arthroplasty. Fixation was associated with reduced need for blood transfusion and lower risk of revision surgery compared with revision arthroplasty. Cite this article: Bone Joint J 2021;103-B(2):309-320.

Population mobility and adult orthopaedic trauma services during the COVID-19 pandemic: fragility fracture provision remains a priority.

AIMS: This study aims to define the epidemiology of trauma presenting to a single centre providing all orthopaedic trauma care for a population of ∼ 900,000 over the first 40 days of the COVID-19 pandemic compared to that presenting over the same period one year earlier. The secondary aim was to compare this with population mobility data obtained from Google. METHODS: A cross-sectional study of consecutive adult (> 13 years) patients with musculoskeletal trauma referred as either in-patients or out-patients over a 40-day period beginning on 5 March 2020, the date of the first reported UK COVID-19 death, was performed. This time period encompassed social distancing measures. This group was compared to a group of patients referred over the same calendar period in 2019 and to publicly available mobility data from Google. RESULTS: Orthopaedic trauma referrals reduced by 42% (1,056 compared to 1,820) during the study period, and by 58% (405 compared to 967) following national lockdown. Outpatient referrals reduced by 44%, and inpatient referrals by 36%, and the number of surgeries performed by 36%. The regional incidence of traumatic injury fell from 5.07 (95% confidence interval (CI) 4.79 to 5.35) to 2.94 (95% CI 2.52 to 3.32) per 100,000 population per day. Significant reductions were seen in injuries related to sports and alcohol consumption. No admissions occurred relating to major trauma (Injury Severity Score > 16) or violence against the person. Changes in population mobility and trauma volume from baseline correlated significantly (Pearson's correlation 0.749, 95% CI 0.58 to 0.85, p < 0.001). However, admissions related to fragility fractures remained unchanged compared to the 2019 baseline. CONCLUSION: The profound changes in social behaviour and mobility during the early stages of the COVID-19 pandemic have directly correlated with a significant decrease in orthopaedic trauma referrals, but fragility fractures remained unaffected and provision for these patients should be maintained.Cite this article: Bone Joint Open 2020;1-6:182-189.

Periprosthetic atypical femoral fractures exist and are associated with duration of bisphosphonate therapy.

AIMS: Currently, periprosthetic fractures are excluded from the American Society for Bone and Mineral Research (ASBMR) definition of atypical femoral fracture (AFFs). This study aims to report on a series of periprosthetic femoral fractures (PFFs) that otherwise meet the criteria for AFFs. Secondary aims were to identify predictors of periprosthetic atypical femoral fractures (PAFFs) and quantify the complications of treatment. PATIENTS AND METHODS: This was a retrospective case control study of consecutive patients with periprosthetic femoral fractures between 2007 and 2017. Two observers identified 16 PAFF cases (mean age 73.9 years (44 to 88), 14 female patients) and 17 typical periprosthetic fractures in patients on bisphosphonate therapy as controls (mean age 80.7 years (60 to 86, 13 female patients). Univariate and multivariate analysis was performed to identify predictors of PAFF. Management and complications were recorded. RESULTS: Interobserver agreement for the PAFF classification was excellent (kappa = 0.944; p < 0.001). On univariate analysis compared with controls, patients with PAFFs had higher mean body mass indices (28.6 kg/m2 (sd 8.9) vs 21.5 kg/m2 (sd 3.3); p = 0.009), longer durations of bisphosphonate therapy (median 5.5 years (IQR 3.2 to 10.6) vs 2.4 years (IQR 1.0 to 6.4); p = 0.04), and were less likely to be on alendronate (50% vs 94%; p = 0.02) with an indication of secondary osteoporosis (19% vs 0%; p = 0.049). Duration of bisphosphonate therapy was an independent predictor of PAFF on multivariate analysis (R2 = 0.733; p = 0.05). Following primary fracture management, complication rates were higher in PAFFs (9/16, 56%) than controls (5/17, 29%; p = 0.178) with a relative risk of any complication following PAFF of 1.71 (95% confidence interval (CI) 0.77 to 3.8) and of reoperation 2.56 (95% CI 1.3 to 5.2). CONCLUSION: AFFs do occur in association with prostheses. Longer duration of bisphosphonate therapy is an independent predictor of PAFF. Complication rates are higher following PAFFs compared with typical PFFs, particularly of reoperation and infection. Cite this article: Bone Joint J 2019;101-B:1285-1291.

Revision of Unicompartmental to Total Knee Arthroplasty: Does the Unicompartmental Implant (Metal-Backed vs All-Polyethylene) Impact the Total Knee Arthroplasty?

BACKGROUND: The aim of this study is to investigate differences in implant requirement, outcomes, and re-revision when total knee arthroplasty (TKA) was performed following unicompartmental knee arthroplasties (UKAs) with metal-backed (MB) compared to all-polyethylene (AP) tibial components. METHODS: Retrospective study of 60 UKAs converted to 60 TKAs at mean 7.3 years (0.1 to 17) after implantation in 55 patients (mean age, 64 [49-83]; 44% male): 44 MB and 16 AP. TKA implant requirement was investigated in addition to mode of failure, Oxford Knee Score, and TKA survival at mean 5.4 years (0.5 to 17). RESULTS: Progression of osteoarthritis was the commonest mode of failure in MB UKAs (P = .03) and unexplained pain in AP (P = .011) where revisions were performed earlier (4.8 ± 3.2 vs 8.2 ± 4.5, P = .012). In 56 of 60 (93%) cases, unconstrained TKA implants were used. The use of standard cruciate-retaining TKAs without augments or stems was less likely following MB UKA compared to AP (12 of 38 [32%] vs 10/14 [71%], P = .013). Specifically MB UKA implants were associated with more tibial stem use (P = .04) and more use of cruciate-substituting polyethylene (P = .05). There was no difference in the use of constrained implants. Multivariate analysis showed tibial resection depth to predict stem requirement. Seven were re-revised giving 7-year TKA survival: from MB UKA 70.3 (95% CI, 47.0 to 93.6) and from AP UKA 87.5 (95% CI, 64.6 to 100; P = .191). CONCLUSION: MB UKA implants increase the chances of a complex revision requiring tibial stems and cruciate substitution but reduce the chances of early revision compared to AP UKA which often fail early with pain.

Results of a national multicenter audit assessment of gynecologic history in surgical patients.

OBJECTIVE: To determine the adequacy of assessing gynecologic history for females of reproductive age (FRA) admitted to a general surgery department. METHODS: The present prospective multicenter audit included FRA who were admitted for elective or emergency procedures to general surgery departments in Scotland between May 11 and May 25, 2015. Data were compared between patients who were admitted for elective and emergency treatment. RESULTS: There were 530 FRA included from 18 centers, including 169 (31.9%) and 361 (68.1%) elective and emergency admissions, respectively. The date of last menstrual period was document for 203 (38.3%) patients, use of contraception for 149 (28.1%), sexual activity for 83 (15.7%), pregnancy status for 274 (51.7%), and the possibility of pregnancy for 237 (44.7%). A higher incidence of documented date of last menstrual period (P=0.002) and pregnancy status (P<0.001) were identified among emergency admissions, and the possibility of pregnancy was documented more commonly among elective admissions (P<0.001). CONCLUSIONS: Key factors required for gynecologic assessment were often not documented for FRA admitted to general surgery both as elective and emergency admissions. Surgical teams and medical undergraduates require educating regarding the importance of obtaining gynecologic history for all FRA.

National multicentre audit of pregnancy status in general surgery admissions in Scotland.

BACKGROUND: Documentation of pregnancy status (PS) is an integral component of the assessment of women of reproductive age when admitted to hospital. Our aim was to determine how accurately PS was documented in a multicentre audit of female admissions to general surgery. METHODS: A prospective multicentre audit of elective and emergency admissions was performed in 18 Scottish centres between 08:00 on 11 May 2015 and 07:59 on 25 May 2015. The lower age limit was the minimum age for admission to the adult surgical ward and the upper age limit was 55 years. RESULTS: There were 2743 admissions, with 612 (22.3%) women of reproductive age. After 82 exclusions, the final total was 530: 169 (31.9%) elective and 361 (68.1%) emergency. Documentation of PS was achieved in 274 (51.7%) cases: 52 (30.8%) elective and 222 (61.5%) emergency. In 318 (88.1%) of the emergency admissions, the patient had abdominal pain. Of these, 211 (65.1%) had a documented PS. The possibility of pregnancy was established in 237 (44.7%) cases. DISCUSSION: Establishing the possibility of pregnancy before surgery is poor, particularly in the elective setting. Objective documentation of PS in the emergency setting in those with abdominal pain is also poor. Our study highlights an important safety issue in the management of female patients. We advocate electronic storage of pregnancy test results and new guidelines to cover both elective and emergency surgery. PS should form part of the pre-theatre safety brief and checklist.

Can release of urinary retention trigger abdominal aortic aneurysm rupture?

Only 50% of abdominal aortic aneurysms present with the classic triad of hypotension, back pain and a pulsatile abdominal mass. This variability in symptoms can delay diagnosis and treatment. We present the case of a patient presenting with a unique combination of symptoms suggesting that decompression of urinary retention can lead to abdominal aortic aneurysm rupture.