Quality of cementing in hemiarthroplasty for elderly neck of femur fractures does not affect short term functional outcomes.

INTRODUCTION: Cemented hip hemiarthroplasty is a routine surgical option for elderly neck of femur (NOF) fractures. It is uncertain if quality of cementing has any effect on functional outcomes. The aim of this study was to determine if the quality of cementing would affect short term functional outcomes in elderly neck of femur fractures. MATERIALS AND METHODS: Retrospective analysis of 637 single-centre cemented hip hemiarthroplasties from 2014 to 2021 was performed. Each post-operative radiograph was double-read by 2 authors (1 resident and 1 fellowship trained surgeon) to determine quality of cementing via the Barrack grading. Disagreements were reviewed by a third reader. Cement grades were grouped as Optimal (Barrack grade A-B), or Suboptimal (Barrack grade C-D). Functional outcomes were compared using mobility (community- or home-ambulant), assistance required for mobility, and Modified Barthel Index (MBI). Surgical parameters were compared between the groups. RESULTS: There were 429 Optimal and 208 Suboptimal cases of cementing performed. There was no difference in age, American Society of Anesthesiologists score, mobility, assistance required, and MBI score pre-operatively (p > 0.05). Patients in the "Suboptimal" cementing group had a higher Charlson Comorbidity Index (CCI) score (p < 0.001). At 1 year post-operation, there was no significant difference between "Optimal" and "Suboptimal" cementing with regards to the proportion of community ambulators (30.2% vs. 25.7%, p = 0.252), walking independence (independent walkers (19.8% vs.17.3%), independent walkers with aids (41.3%vs.42.1%), walker with caregiver assistance (29.2%vs.33.7%), wheelchair-bound (9.6%vs.6.9%), p = 0.478), and distribution of MBI score (81.1%vs.82.2% achieving MBI > 60, p = 0.767). There was no significant difference in the proportion of patients with postoperative delirium (7.9% vs. 5.8, p = 0.324) or 1-year mortality rates (3.5% vs. 2.9%, p = 0.685). Except for stem design (12.2% tapered vs 20.1% collared; p = 0.011), no other surgical parameters were significantly different. The kappa value for inter-reader agreement was "substantial" at 0.727 (95% CI 0.682-0.772) (p < 0.001). CONCLUSION: Quality of cementing in cemented hip hemiarthroplasty for elderly NOF fractures does not affect the short-term functional outcomes. In low demand patients and patients at risk of BCIS, optimal cementing may not be necessary to achieve similar short-term functional outcomes. Further studies should be conducted to determine the effect of sub-optimal cementing on long-term functional outcomes.

Heat and Acupuncture to Manage Osteoarthritis of the Knee (HARMOKnee): Protocol for an Effectiveness-Implementation Hybrid Randomized Controlled Trial.

BACKGROUND: Knee osteoarthritis (KOA) is one of most prevalent and fastest-growing causes of pain, impaired mobility, and poor quality of life in the rapidly aging population worldwide. There is a lack of high-quality evidence on the efficacy of traditional Chinese medicine (TCM), particularly acupuncture, and a lack of KOA practice guidelines that are tailored to unique population demographics and tropical climates. OBJECTIVE: Our HARMOKnee (Heat and Acupuncture to Manage Osteoarthritis of the Knee) trial aims to address these gaps by evaluating the short- and medium-term clinical and cost-effectiveness of acupuncture with heat therapy in addition to standard care, compared to standard care alone. Through a robust process and economic evaluation, we aim to inform evidence-based practice for patients with KOA to facilitate the large-scale implementation of a comprehensive and holistic model of care that harmonizes elements of Western medicine and TCM. We hypothesize that acupuncture with heat therapy as an adjunct to standard care is clinically more effective than standard care alone. METHODS: A multicenter, pragmatic, parallel-arm, single-blinded, effectiveness-implementation hybrid randomized controlled trial will be conducted. We intend to recruit 100 patients with KOA randomized to either the control arm (standard care only) or intervention arm (acupuncture with heat therapy, in addition to standard care). The inclusion criteria are being a community ambulator and having primary KOA, excluding patients with secondary arthritis or previous knee replacements. The primary outcome measure is the Knee Osteoarthritis Outcome Score at 6 weeks. Secondary outcome measures include psychological, physical, quality of life, satisfaction, and global outcome measures at 6, 12, and 26 weeks. A mixed method approach through an embedded process evaluation will facilitate large-scale implementation. An economic evaluation will be performed to assess financial sustainability. RESULTS: Patient enrollment has been ongoing since August 2022. The recruitment process is anticipated to conclude by July 2024, and the findings will be analyzed and publicized as they are obtained. As of November 6, 2023, our patient enrollment stands at 65 individuals. CONCLUSIONS: The findings of our HARMOKnee study will contribute substantial evidence to the current body of literature regarding the effectiveness of acupuncture treatment for KOA. Additionally, we aim to facilitate the creation of standardized national guidelines for evidence-based practice that are specifically tailored to our unique population demographics. Furthermore, we seek to promote the adoption and integration of acupuncture and heat therapy into existing treatment models. TRIAL REGISTRATION: ClinicalTrials.gov NCT05507619; https://clinicaltrials.gov/study/NCT05507619. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/54352.

Outcomes of ultra-old vs old patients after hip fracture surgery: a matched cohort analysis of 1524 patients.

BACKGROUND: Surgical management of geriatric hip fractures yields improved functional outcomes with decreased morbidity and mortality. Cohort studies have suggested that the older patients within the geriatric age group have worse outcomes with surgery, However, these studies inherently report inflated risks due to poor handling of confounders and have inadequately age-stratified their geriatric population. AIM: This study aims to investigate the effect of age alone on the 1-year mortality and functional status of geriatric patients after hip fracture surgery. METHODS: This is a retrospective single institution cohort study based on the prospectively-maintained registry of hip fracture patients. 2603 patients aged 60 years and above were treated surgically under a geriatric-orthopaedic hip fracture pathway from January 2014 to December 2018. Patients were split into two age groups: ultra-old (≥ 85 years) vs old (< 85 years). Baseline demographics and the ASA (American Society of Anaesthesiologists) status and the Modified Barthel's Index (MBI) were obtained at admission and 1 year after the fracture. Adverse outcomes from the fracture and surgery were recorded during a follow-up period of minimally 2 years. A 2:1 matching process based on the gender, fracture type, ASA status, CCI and MBI categories was conducted. RESULTS: There were 1009 and 515 patients in the old and ultra-old age groups, respectively. 1-year mortality was similar for both age groups (4.0% ultra-old vs 3.6% old, p = 0.703). 30-day morbidity was similar except for higher rates of postoperative pneumonia in the ultra-old (14.0 vs 6.3%, p < 0.001). MBI scores at 1-year were lower in the ultra-old (severe dependence: 16.4 vs 10.0%; p = 0.001). Ultra-old patients were less likely to be community ambulant at 12 months (21.2 vs 36.0%) with the deterioration in ambulatory status significant after correction for baseline status (p < 0.001). CONCLUSION: The 1-year mortality of surgically-managed geriatric hip fracture patients older than 85 years of age is not determined by age alone. Patients aged 85 years and above are at higher risk for pneumonia postoperatively. Ultra-old hip fracture patients with an intertrochanteric fracture are more likely to have poorer function at 1 year after hip fracture surgery.

The effect of patient positioning on the accuracy and reliability of assessment of knee range of motion over a telemedicine platform.

INTRODUCTION: Diagnostic accuracy is one of the key considerations of telemedicine usage in orthopedic surgery. The aim of this study was to determine the optimal patient positioning to achieve accurate and reliable visual estimation of the knee joint range of motion over a digital platform for telemedicine. METHODS: A single volunteer was recruited to perform a total of 120 discrete and random knee range of motion angles in three patient positions: sitting, standing and supine. The patient image was broadcast over a digital platform to six raters. The raters recorded their visual estimation of each discrete knee flexion angle independently. After each discrete knee flexion angle, a physical goniometer was used to obtain the actual flexion angle of the knee. RESULTS: A total of 120 discrete measurements (40 measurements in the sitting, standing, and supine positions each) were recorded by each of the six raters. The supine position resulted in the highest intraclass correlation of 0.97 (95% confidence interval: 0.98, 0.99). All three patient positions achieved low absolute difference between the goniometer and the raters with 5.6 degrees (95% limits of agreement: -21.0, 9.8) in sitting, 2.7 degrees (95% limits of agreement: -10.1, 15.4), and 1.2 degrees (95% limits of agreement: -9.8, 12.3) in the supine position. The supine position had the highest accuracy and reliability. DISCUSSION: Visual estimation of the knee joint range of motion over telemedicine is clinically accurate and reliable. Patients should be assessed in a supine position to obtain the highest accuracy and reliability for visual estimation of the knee joint range of motion during telemedicine.

Functional Outcomes of Patients with Schizophrenia After Hip Fracture Surgery: A 1-Year Follow-up from an Institutional Hip Fracture Registry.

BACKGROUND: Schizophrenia impairs a patient's self-care abilities, which are crucial after a hip fracture. Studies on the outcomes of patients with schizophrenia after a hip fracture are dated. This study aims to investigate the complication rates, 1-year mortality, and functional outcomes of surgically managed hip fractures in elderly patients with schizophrenia. METHODS: This is a retrospective, single-institution cohort study based on a prospectively maintained registry of patients with hip fracture. In this study, 3,056 patients who were ≥60 years of age were treated under a geriatric-orthopaedic hip fracture pathway from January 2014 to December 2018. Baseline demographic characteristics and the Modified Barthel Index (MBI) scores were obtained at admission and at 6 months and 1 year after the fracture. Complications from the fracture and the surgical procedure were recorded during a minimum follow-up period of 2 years. A matching process (based on age, sex, and the MBI at admission) of up to 6 patients without schizophrenia per 1 patient with schizophrenia was utilized to increase power. Differences in perioperative, 6-month, and 1-year outcomes were compared for significance among surgically managed patients with schizophrenia and patients without schizophrenia. RESULTS: Thirty-eight patients with schizophrenia were compared with 170 geriatric patients without schizophrenia who underwent a surgical procedure for a hip fracture. Patients with schizophrenia were more likely to be institutionalized postoperatively (26.3% compared with 4.7%; p < 0.001). Patients with schizophrenia had poorer MBI scores at 12 months (76 compared with 90 points; p = 0.006). The 1-year mortality rate was comparable (p = 0.29) between patients with schizophrenia (5.7%) and those without schizophrenia (2.4%). Similar trends in MBI were observed in the conservatively managed group of patients. CONCLUSIONS: There was no increase in postoperative complications after a surgical procedure for a hip fracture in elderly patients with schizophrenia. The 1-year mortality after a surgical procedure for hip fracture is similar in both patients with schizophrenia and those without schizophrenia. Patients with schizophrenia and hip fracture who were surgically managed had poorer 1-year functional outcomes compared with patients without schizophrenia matched for age, sex, and MBI at admission. This information will be useful in shared decision-making discussions with patients and families. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Hemiarthroplasty in the Hip Fracture Patient with Renal Impairment: To Cement or Not to Cement.

PURPOSE: Patients with chronic kidney disease (CKD) have a higher risk of complications when undergoing hip hemiarthroplasty. The primary aim is to test the null hypothesis that there is no difference between cemented and uncemented stem loosening rates in patients with CKD who receive a hip hemiarthroplasty for femoral neck fractures. The secondary aim is to determine the effect of increasing severity of renal disease on the rate of stem loosening in this CKD patient subset. MATERIALS AND METHODS: A retrospective study of all patients with CKD who underwent a hip hemiarthroplasty for a traumatic femoral-neck fracture between 2003 and 2013 was performed. Patients with a minimum of two-year follow-up were included; those with pathological fractures or loosening due to infection were excluded. The outcome measure was radiographic aseptic loosening of the stem, defined as progressive radiolucency of more than 2 mm, progressive subsidence or migration of the implant. RESULTS: One-hundred and nineteen cases were included in this study. Loosening occurred in 11 cases (9.24%). A comparison between cemented and uncemented groups revealed no difference in the rate of loosening (P=0.079). In all cases, worsening renal function did not increase the rate of loosening (P=0.311). The rate of loosening did not increase with worsening renal function in either the cemented (P=0.678) or uncemented groups (P=0.307). CONCLUSION: There is no difference in the rate of loosening between cemented and uncemented hemiarthroplasty for femoral neck fractures in the elderly with CKD. The rate of loosening did not increase with worsening renal function. All patients with renal impairment, not just those with end-stage renal failure, warrant close follow-up as early loosening can occur throughout the entire spectrum of renal disease.

Total Knee Arthroplasty in Ochronosis Arthropathy: A Case Report and Systematic Review.

INTRODUCTION: Ochronosis arthropathy (OcA) is a rare condition which may be treated with total knee arthroplasty (TKA) at the end stage. The condition is often discovered only intraoperatively and the ideal choice of TKA is unknown. CASE PRESENTATION: A 54-year-old male with worsening chronic bilateral mechanical knee pain had failed conservative therapy. Posterior stabilised (PS), cemented TKA and patella resurfacing was performed. Intraoperatively, collagenous structures such as the menisci and cartilage were noted to be black. Histological examination showed deposition of large amorphous brown material suggestive of ochronosis. He recovered well and underwent TKA of the contralateral knee the following year. At 2 years postindex TKA, his outcome scores improved and he was satisfied. DISCUSSION AND CONCLUSION: With increasing TKA performed worldwide, a surgeon may eventually be surprised by the above findings once in their lifetime. However, OcA may be considered a likely diagnosis and it is safe to proceed with TKA. There is no particular TKA design that proved to be superior in our systematic review of 19 publications regarding TKA as all reported good outcomes. However, as the pathogenesis of OcA appears to be inflammatory in nature, we suggest using cemented PS TKA with resurfacing of the patella.

Infection rates in Singaporeans with and without complicated diabetes after ankle fracture surgery.

PURPOSE: To compare infection rates in Singaporeans with and without complicated diabetes after ankle fracture surgery. METHODS: Medical records of 18 men and 27 women aged 38 to 84 (mean, 62) years with complicated (n=12) or uncomplicated (n=33) diabetes who underwent internal fixation for closed ankle fractures were reviewed. Complicated diabetes was defined as having end organ dysfunction. The control of diabetes was categorised as good (n=19), fair (n=10), and poor (n=16), based on HbA1c level within 4 months before or after surgery. Patients were followed up at weeks 2, 6, 12, and 24, with bone union as the end point. RESULTS: The mean follow-up period was 9 (range, 4-12) months. 2 (6%) of 33 patients with uncomplicated diabetes and 6 (50%) of 12 patients with complicated diabetes developed superficial or deep infection. No patient died or underwent amputation secondary to infection. In multivariable logistic regression analysis after adjusting for co-morbidities, only complicated diabetes was a risk factor for postoperative infection (odds ratio=11.85, p=0.01). The odds of postoperative infection was 11.85 times higher in patients with complicated diabetes than with uncomplicated diabetes. CONCLUSION: In patients with complicated diabetes, careful patient selection, peri-operative precaution, and closer monitoring are recommended if surgery is necessary.