One-year postoperative mortality rate among the elderly with hip fractures at a single tertiary care center.

BACKGROUND: Hip fractures are one of the leading causes of disability and dependency among the elderly. The rate of hip fractures has been progressively increasing due to the continuing increase in average life expectancy. Surgical intervention is the mainstay of treatment, but with an increasing prevalence of comorbid conditions and decreased functional capacity in elderly patients, more patients are prone to postoperative complications. OBJECTIVES: Assess the value of surgical intervention for hip fractures among the elderly by quantifying the 1-year mortality rate and assessing factors associated with mortality. DESIGN: Medical record review. SETTING: Tertiary care center. PATIENTS AND METHODS: All patients 60 years o age or older who sustained a hip fracture between the period of 2008 to 2018 in a single tertiary healthcare center. Data was obtained from case files, using both electronic and paper files. MAIN OUTCOME MEASURES: The 1-year mortality rate for hip fracture, postoperative complications and factors associated with mortality. SAMPLE SIZE: 802 patients. RESULTS: The majority of patients underwent surgical intervention (93%). Intra- and postoperative complications were 3% and 16%, respectively. Four percent of the sample died within 30 days, and 11% died within one year. In a multivariate analysis, an increased risk of 1-year mortality was associated with neck of femur fractures and postoperative complications (P=.034, <.001, respectively) CONCLUSION: The 1-year mortality risk in our study reinforces the importance of aggressive surgical intervention for hip fractures. LIMITATION: Single-centered study. CONFLICT OF INTEREST: None.

Multicentre randomised double-blind placebo controlled trial of combination vancomycin and cefazolin surgical antibiotic prophylaxis: the Australian surgical antibiotic prophylaxis (ASAP) trial.

INTRODUCTION: Resistant Gram-positive organisms, such as methicillin-resistant staphylococci, account for a significant proportion of infections following joint replacement surgery. Current surgical antimicrobial prophylaxis guidelines recommend the use of first-generation or second-generation cephalosporin antibiotics, such as cefazolin. Cefazolin, however, does not prevent infections due to these resistant organisms; therefore, new prevention strategies need to be examined. One proposed strategy is to combine a glycopeptide antibiotic with cefazolin for prophylaxis. The clinical benefit and cost-effectiveness of this combination therapy compared with usual therapy, however, have not been established. METHODS AND ANALYSIS: This randomised, double-blind, parallel, superiority, placebo-controlled, phase 4 trial will compare the incidence of all surgical site infections (SSIs) including superficial, deep and organ/space (prosthetic joint) infections, safety and cost-effectiveness of surgical prophylaxis with cefazolin plus vancomycin to that with cefazolin plus placebo. The study will be performed in patients undergoing joint replacement surgery. In the microbiological sub-studies, we will examine the incidence of SSIs in participants with preoperative staphylococci colonisation (Sub-Study 1) and incidence of VRE acquisition (Sub-Study 2). The trial will recruit 4450 participants over a 4-year period across 13 orthopaedic centres in Australia. The primary outcome is the incidence of SSI at 90 days post index surgery. Secondary outcomes include the incidence of SSI according to joint and microorganism and other healthcare associated infections. Safety endpoints include the incidence of acute kidney injury, hypersensitivity reactions and all-cause mortality. The primary and secondary analysis will be a modified intention-to-treat analysis consisting of all randomised participants who undergo eligible surgery. We will also perform a per-protocol analysis. ETHICS AND DISSEMINATION: The study protocol was reviewed and approved by The Alfred Hospital Human Research Ethics Committee (HREC/18/Alfred/102) on 9 July 2018. Study findings will be disseminated in the printed media, and learnt forums. TRIAL REGISTRATION NUMBER: ACTRN12618000642280.

Change in the cause of inpatient mortality after arthroplasty: a retrospective study.

BACKGROUND: Although arthroplasty has been proved to be a safe and effective procedure, data regarding inpatient mortality rates associated with arthroplasty in China is unclear. We aimed to investigate the inpatient mortality rate after arthroplasty and the determinants of mortality at our center to ensure improved perioperative management. METHODS: This retrospective study included all patients who underwent arthroplasty at our center. Clinical data of mortality patients were collected. The incidence and the causes of inpatient mortality after arthroplasty were analyzed. RESULTS: A total of 4176 total knee arthroplasties, 2164 total hip arthroplasties, and 1031 femoral head replacements were performed. A rapid growth in surgery volume was observed, and more than 50% of the surgeries were performed in the last 5 years. The overall inpatient mortality rate is 0.3%; however, the mortality rate even decreased in the last 5 years. The cause of death changed over time. Pneumonia has become the leading cause of death in the past 5 years instead of cardiovascular complications. CONCLUSIONS: Arthroplasty is a safe and effective procedure associated with a relatively low inpatient mortality in China. And inpatient mortality does not increase as the growing surgery volume due to improvement of perioperative management. However, patients presenting with risk factors and those undergoing non-elective procedures demonstrated a relatively high incidence of postoperative complications, particularly pneumonia.

There is no 'weekend effect' in elective orthopaedic surgery.

Introduction The 'weekend effect' is said to occur when patient outcomes are adversely affected by the day of the week on which they present to hospital or have surgery. However, it is uncertain whether such a phenomenon exists for elective orthopaedic surgery. We investigated whether there is a 'weekend effect' in elective orthopaedic patients. Methods Retrospectively collected data were obtained from our institution's electronic patient records. We collected demographic and International Statistical Classification of Diseases and Related Health Problems tenth revision coding data for all included patients. Multivariate analyses identified covariate-adjusted risk factors, associated with prolonged stays. Thirty-day mortality data were assessed according to the day on which surgery occurred. Results We analysed data for 892 patients over a one-year period. During the year, 457 patients had a total hip and 435 had a total knee replacement; 814 patients (91.3%) underwent surgery during the week, while 78 (8.7%) had surgery on a Saturday. There was no difference in average length of stay between the groups (5.0, 2.6 vs 5.0, 3.4, P = 0.95). Variables associated with prolonged hospitalisation included increasing age (covariate adjusted relative risk 1.02, 95% confidence interval 1.01-1.03, P < 0.001) and an American Society of Anesthesiologists score of 2, (relative risk 1.6, 95% confidence interval 1.15-2.20, P = 0.005). There was one death in a patient who underwent surgery on a Monday. Conclusions There is no 'weekend effect' for elective orthopaedic surgery.

Pre-fracture hospitalization is associated with worse functional outcome and higher mortality in geriatric hip fracture patients.

Hip fractures are common in elderly people. Despite great progress in surgical care, the outcomes of these patients remain disappointing. This study determined pre-fracture hospital admission as a prognostic variable for inferior functional outcomes and increased mortality rates in the perioperative phase and in the first postoperative year. PURPOSE: The influence of a pre-fracture hospitalization on outcomes in hip fracture patients has not yet been investigated. METHODS: Four hundred two patients who were surgically treated for hip fracture were prospectively enrolled. Patients with a hospital stay within the last 3 months prior to a hip fracture were compared to patients without a pre-fracture hospitalization. Postoperative functional outcomes and mortality rates were compared between groups at the time of hospital discharge and additionally at the six- and twelve-month follow-up appointments. A multivariate regression analysis was performed. RESULTS: A pre-fracture hospitalization was reported by 67 patients (17%). In 63% of cases, patients were admitted due to non-surgical, general medical conditions. In 37% of cases, patients were treated due to a condition related to a surgical subject. In the multivariate analysis, pre-fracture hospitalization was an independent risk factor for reduced values on the Barthel Index at 6 months after surgery (B, -9.918; 95%CI of B, -19.001--0.835; p = 0.032) and on the Tinetti Test at 6 months (B, -2.914; 95%CI of B, -1.992--0.047; p = 0.047) and 12 months after surgery (B, -4.680; 95%CI of B, -8.042--1.319; p = 0.007). Pre-fracture hospitalization was additionally associated with increased mortality rates at 6 months (OR 1.971; 95%CI 1.052-3.693; p = 0.034) and 12 months after surgery (OR 1.888; 95%CI 1.010-9.529; p = 0.046). CONCLUSIONS: Hip fracture patients with a recent pre-fracture hospital admission are at a substantial risk for inferior functional outcomes and increased mortality rates not only in the perioperative phase but also in the first postoperative year. As a simple dichotomous variable, pre-fracture hospitalization might be a suitable tool for future geriatric hip fracture screening instruments.

Evaluation of the ProPublica Surgeon Scorecard "Adjusted Complication Rate" Measure Specifications.

OBJECTIVES: The ProPublica Surgeon Scorecard is the first nationwide, multispecialty public reporting of individual surgeon outcomes. However, ProPublica's use of a previously undescribed outcome measure (composite of in-hospital mortality or 30-day related readmission) and inclusion of only inpatients have been questioned. Our objectives were to (1) determine the proportion of cases excluded by ProPublica's specifications, (2) assess the proportion of inpatient complications excluded from ProPublica's measure, and (3) examine the validity of ProPublica's outcome measure by comparing performance on the measure to well-established postoperative outcome measures. METHODS: Using ACS-NSQIP data (2012-2014) for 8 ProPublica procedures and for All Operations, the proportion of cases meeting all ProPublica inclusion criteria was determined. We assessed the proportion of complications occurring inpatient, and thus not considered by ProPublica's measure. Finally, we compared risk-adjusted performance based on ProPublica's measure specifications to established ACS-NSQIP outcome measure performance (eg, death/serious morbidity, mortality). RESULTS: ProPublica's inclusion criteria resulted in elimination of 82% of all operations from assessment (range: 42% for total knee arthroplasty to 96% for laparoscopic cholecystectomy). For all ProPublica operations combined, 84% of complications occur during inpatient hospitalization (range: 61% for TURP to 88% for total hip arthroplasty), and are thus missed by the ProPublica measure. Hospital-level performance on the ProPublica measure correlated weakly with established complication measures, but correlated strongly with readmission (R = 0.834, P < 0.001). CONCLUSIONS: ProPublica's outcome measure specifications exclude 82% of cases, miss 84% of postoperative complications, and correlate poorly with well-established postoperative outcomes. Thus, the validity of the ProPublica Surgeon Scorecard is questionable.

Age-related differences in the use of total shoulder arthroplasty over time: use and outcomes.

We assessed the age-related differences in the use of total shoulder arthroplasty (TSA) and outcomes, and associated time-trends using the United States Nationwide Inpatient Sample (NIS) between 1998 and 2010. Age was categorised as < 50, 50 to 64, 65 to 79 and ≥ 80 years. Time-trends in the use of TSA were compared using logistic regression or the Cochran Armitage test. The overall use of TSA increased from 2.96/100 000 in 1998 to 12.68/100,000 in 2010. Significantly lower rates were noted between 2009 and 2010, compared with between 1998 and 2000, for: mortality, 0.1% versus 0.2% (p = 0.004); discharge to an inpatient facility, 13.3% versus 14.5% (p = 0.039), and hospital stay > median, 29.4% versus 51.2% (p < 0.001). The rates of use of TSA/100,000 by age groups, < 50, 50 to 64, 65 to 79 and ≥ 80 years were: 0.32, 4.62, 17.82 and 12.56, respectively in 1998 (p < 0.001); and 0.65, 17.49, 75.27 and 49.05, respectively in 2010 (p < 0.001) with an increasing age-related difference over time (p < 0.001). Across the age categories, there were significant differences in the proportion: discharged to an inpatient facility, 3.2% versus 4.2% versus 14.7% versus 36.5%, respectively in 1998 (p < 0.001) and 1.8% versus 4.3% versus 12.5% versus 35.5%, respectively in 2010 (p < 0.001) and the proportion with hospital stay > median, 39.7% versus 40.2% versus 53% versus 69%, respectively in 1998 (p < 0.001) and 17.2% versus 20.6% versus 28.7% versus 50.7%, respectively in 2010 (p < 0.001). In a nationally representative sample, we noted a time-related increase in the use of TSA and increasing age-related differences in outcomes indicating a changing epidemiology of the use of TSA. Age-related differences in outcomes suggest that attention should focus on groups with the worst outcomes.

From the risk analysis to the development of interventions and training for the prevention and control of healthcare associated infections. The experience of G. Pini Orthopedic Institute.

BACKGROUND: Health-care associated infections (HAIs) represents a phenomenon of central importance all over Europe. Every year 4,5 millions cases are detected in European Union, with 37.000 related deaths. Surgical-site infections (SSIs) are one of the most common HAIs, that are associated with an increased length of stay, re-operation rate, intensive care admissions rate, and higher mortality rate. METHODS: G. Pini Orthopedics Institute implemented in the last two years a multimodal strategy for controlling and preventing HAIs, in particular for SSIs. RESULTS: This paper describes the prevention's strategies adopted for prevention of HAIs, at G. Pini Orthopedic Institute. CONCLUSIONS: Our findings show that application of a multi modal promotion strategy was associated with an improvement in HAI prevention.

Bone cement implantation syndrome in cemented hemiarthroplasty for femoral neck fracture: incidence, risk factors, and effect on outcome.

BACKGROUND: Bone cement implantation syndrome (BCIS) is characterized by hypoxia, hypotension, and loss of consciousness occurring around the time of bone cementation. Using a recently proposed severity classification of BCIS, we estimated the incidence of and risk factors for BCIS and its impact on mortality in cemented hemiarthroplasty for femoral neck fractures. METHODS: In this retrospective study, 1016 patients undergoing cemented hemiarthroplasty were included. Medical history and medication were obtained from medical records. Anaesthesia charts for all patients were reviewed for mean arterial pressure, arterial oxygen saturation, and heart rate before, during, and after cementation. Each patient was classified as having no BCIS (grade 0) or BCIS grade 1, 2, or 3, depending on the degree of hypotension, arterial desaturation, or loss of consciousness around cementation. RESULTS: The incidence of BCIS grade 1, 2, and 3 were 21%, 5.1%, and 1.7%, respectively. Early mortality in BCIS grade 1 (9.3%) did not differ significantly from BCIS grade 0 (5.2%), while early mortality in BCIS grade 2 (35%) and grade 3 (88%) were significantly higher when compared with grades 0 and 1. Early mortality was also higher in BCIS grade 3 when compared with grade 2. Independent predictors for severe BCIS were: ASA grade III-IV, chronic obstructive pulmonary disease, and medication with diuretics or warfarin. Severe BCIS was associated with 16-fold increase in mortality. CONCLUSIONS: BCIS is a commonly occurring phenomenon in cemented hemiarthroplasty and severe BCIS has a huge impact on early and late mortality.

Managing acetabular fractures in the elderly with fixation and primary arthroplasty: aiming for early weightbearing.

BACKGROUND: Osteoporotic acetabular fractures in the elderly are becoming more common. Regardless of treatment, most patients are managed with a period of protected weightbearing, even if a THA has been performed. We have tried to treat these patients analogously to geriatric femoral neck fractures in a way that allows immediate full weightbearing. QUESTIONS/PURPOSES: We determined return to mobility, length of hospital stay (LOS), radiographic outcomes, and complications in a series of elderly osteoporotic patients treated for acetabular fractures with early fracture fixation and simultaneous THA, allowing full weightbearing immediately postoperatively. METHODS: Since 2009, one surgeon (MR) used a consistent approach for fracture fixation and THA with immediate weightbearing in all patients older than 65 years with acetabular fractures who were fit for surgery and whose injuries were deemed osteoporotic fractures (low-energy mechanisms) meeting particular radiographic criteria (significant marginal impaction or femoral head damage). Twenty-four patients met these criteria and were reviewed at a mean of 24 months (range, 8-38 months). Mean age was 77 years (range, 63-90 years), and eight patients were women. The surgical technique included plate stabilization of both acetabular columns plus simultaneous THA using a tantalum socket and a cemented femoral stem. Clinical and note reviews were conducted to ascertain return to mobility, LOS, and postoperative complications. Component migration and fracture healing were assessed on plain radiographs. RESULTS: All patients mobilized with full weightbearing by Day 7 postoperatively. Only one patient remained dependent on a frame to mobilize at discharge. At 6 weeks, two patients already required no walking aids. At 6 months, patients were using a single stick at home at most, and all patients had managed stairs. Mean LOS was 18 days (range, 10-36 days). Radiographically, no component migration was seen in any patient. Seventeen of 24 fractures (71%) healed radiographically by 12 weeks, and all healed by 6 months. We recorded one superficial wound infection, one symptomatic deep venous thrombosis, and one in-hospital death from myocardial infarction. CONCLUSIONS: Selected older patients with acetabular fractures may be managed using immediate weightbearing after fracture fixation and THA. However, this surgery is complex and requires a mixed skill set. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

[Comparing effectivity of VAC therapy for treatment of infections following arthroplasty or soft-tissue surgery]. / Vergleich der Effektivität der VAC-Therapie bei der Behandlung von Prothesen- und Weichteilinfektionen.

BACKGROUND: Although vacuum-assisted wound closure (VAC) has been developed into a standard technique in septic surgery, reliable data about the efficacy of the treatment are still lacking. PATIENTS: Postoperative infections after arthroplasty or soft-tissue surgery were identified using a prospective database for complications (Critical Incidence Reporting System) which was retrospectively supplemented with items for evaluation of VAC therapy. Eradication success of infection was analysed considering epidemiological parameters, course of treatment, and characteristics of causing bacterial strains. Furthermore, serological C-reactive protein (CRP) concentrations were evaluated for diagnostic and prognostic reliability. RESULTS: 92 patients with an average age of 60 ± 4 years were included in the study. Patients with soft tissue infections (STI, n = 53) were statistically significant younger compared to patients with infections following arthroplasty (AI, n = 39) (53 ± 6 vs. 70 ± 4 years; p < 0.001), but the probability for eradication success was not dependent on age. Mortality was 9-fold higher in the AI group (p < 0.01). Patients with infected endoprostheses were longer treated on intensive care units (6.1 ± 8.4 vs. 3.5 ± 6.5 days; p < 0.01), but there was no statistically significant association to eradication success. Probability for eradication of infection was with 81 % statistically significant higher in the STI group compared to 38 % in the AI group (p < 0.001). Early infections in the AI group were associated with a better healing success when compared to chronic infections (p < 0.05). The same correlation could be shown for the removal of implant (p < 0.0001). Aerobic fermenting bacteria were less effectively eradicated than anaerobic germs following soft-tissue infections (p < 0.01). In cases of osteomyelitis following soft-tissue infection, the probability for eradication of infection was impaired (p < 0.001). Kind and quality of final wound closure in the STI group were statistically significantly associated with eradication success (p < 0.001). There was no critical value concerning the number of revisions until healing of infection was reached. CRP values were higher in the AI group and associated with the prognosis (p < 0.05). CONCLUSION: Probability of eradication success using VAC therapy is higher after soft-tissue infections compared to infections following arthroplasty. Accordingly, mortality is higher in this group. Chronic courses have worse chances for healing in both groups. For serological CRP values a prognostic relevance could be shown.

Prophylactic stabilization for bone metastases, myeloma, or lymphoma: do we need to protect the entire bone?

BACKGROUND: The current operative standard of care for disseminated malignant bone disease suggests stabilizing the entire bone to avoid the need for subsequent operative intervention but risks of doing so include complications related to embolic phenomena. QUESTIONS/PURPOSES: We questioned whether progression and reoperation occur with enough frequency to justify additional risks of longer intramedullary devices. METHODS: A retrospective chart review was done for 96 patients with metastases, myeloma, or lymphoma who had undergone stabilization or arthroplasty of impending or actual femoral or humeral pathologic fractures using an approach favoring intramedullary fixation devices and long-stem arthroplasty. Incidence of progressive bone disease, reoperation, and complications associated with fixation and arthroplasty devices in instrumented femurs or humeri was determined. RESULTS: At minimum 0 months followup (mean, 11 months; range, 0-72 months), 80% of patients had died. Eleven of 96 patients (12%) experienced local bony disease progression; eight had local progression at the original site, two had progression at originally recognized discretely separate lesions, and one had a new lesion develop in the bone that originally was surgically treated. Six subjects (6.3%) required repeat operative intervention for symptomatic failure. Twelve (12.5%) patients experienced physiologic nonfatal complications potentially attributable to embolic phenomena from long intramedullary implants. CONCLUSIONS: Because most patients in this series were treated with the intent to protect the bone with long intramedullary implants when possible, the reoperation rate may be lower than if the entire bone had not been protected. However, the low incidence of disease progression apart from originally identified lesions (one of 96) was considerably lower than the physiologic complication rate (12 of 96) potentially attributable to long intramedullary implants. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Evaluación de indicadores en artroplastia: año 2008 / Evaluation of indicators in arthroplasty: year 2008

Objetivo: Estimar indicadores que permitan medir el desempeño de los centros que realizan\r\nartroplastias bajo la cobertura financiera del FNR. Material y Métodos: Indicadores: Se diseñaron y calcularon los siguientes indicadores: Indicadores de Proceso: a) Tiempo entre la fractura y la cirugía menor a 7 días. Indicadores de Resultado: b) Mortalidad Operatoria Cruda. c) Mortalidad Cruda al Año. d) Mortalidad al Año Ajustada por Riesgo Preoperatorio en artroplastia de cadera por fractura. e) Incidencia de Infección Profunda de Sitio Quirúrgico (ISQ). f) Incidencia de Re-intervenciones antes del año de la artroplastia. g) Incidencia de Luxaciones antes del año de la artroplastia. h) Indicadores Funcionales al año. i) Incidencia de Solicitud de Recambios. Se estudiaron los indicadores referidos en los pacientes en quienes se realizó una\r\nartroplastia bajo la cobertura del FNR en el año 2008. Muestreo: para los indicadores ISQ, reintervenciones, luxaciones e indicadores funcionales, se tomó una muestra no proporcional, estratificada por IMAE y por tipo de cirugía. Los IMAE MUCAM y COMEPA se censaron y de los otros IMAE se obtuvieron muestras. Las fracciones de muestreo fueron: a) Artroplastia de Cadera por Artrosis. b) Artroplastia de Cadera por Fractura. c) Artroplastia de Rodilla. La población muestreada correspondió a todos los procedimientos de artroplastia realizados durante el año 2008 bajo la cobertura financiera del FNR. Definiciones: mortalidad Operatoria; mortalidad al año; mortalidad esperada al año en artroplastia de cadera por artrosis; infección de sitio quirúrgico profunda; re-intervención; escala de movilidad; escala de dolor. Fuentes de Datos: Los datos analizados fueron obtenidos de: a) los formularios de solicitud y realización\r\nde la artroplastia que son enviados al FNR por los médicos tratantes y por el cirujano que realiza la cirugía, b) las entrevistas telefónicas realizada a la muestra de pacientes y c) los datos de mortalidad fueron obtenidos de la base de datos de Registros Médicos del FNR.

Functional outcome, mortality and in-hospital complications of operative treatment in elderly patients with hip fractures in the developing world.

Hip fracture has been increasing in frequency for several decades, and 70-90% of patients who sustain a hip fracture survive for at least one year. Many of these survivors fail to regain their prefracture functional status. No work in this regard has been done in the developing world. Elderly patients with acute intertrochanteric fracture and fracture of the femoral neck were followed up prospectively for 12 months after surgery to record the mortality, morbidity, functional status and complications. Three hundred and forty-five patients (61% female) were assessed at six and 12 months after surgery, which included 62.9% intertrochanteric fractures and 37% femoral neck fractures. The mechanism of injury was from a fall in 67% of the cases. Nineteen patients died within six months after surgery while another eight died during the next six months. Obesity, male gender, multiple comorbidities and below normal ambulation status before fracture were identified as major determinants of bad functional outcome.

Displaced femoral neck fractures in the elderly: disposition and outcome after 3- to 6-year follow-up evaluation.

This study evaluated the relationship of the disposition and outcome of patients with displaced femoral neck fractures with the type of surgical treatment. From 1993 to 1996, 186 patients with displaced femoral neck fractures who were 65 years of age or older were treated at one hospital. One hundred and twenty fractures were treated with reduction and internal fixation; 66 were treated with arthroplasty. The time interval from fracture to death and to repeat surgery was significantly less for the internal fixation group than for the arthroplasty group. The possibility of nursing home residence is increased in patients who were treated with reduction and internal fixation compared with patients who were treated with arthroplasty.

Ninety-day mortality after shoulder arthroplasty.

Although mortality associated with knee and hip arthroplasty has been reported, there is no information about shoulder arthroplasty. The purpose of this study was to determine the incidence and risk factors associated with perioperative mortality after shoulder arthroplasty. Between 1970 and 2000, 2,953 patients underwent shoulder arthroplasty at our institution. A retrospective review identified all patients who died within 90 days of the procedure. The 90-day mortality incidence was 0.58% (17 of 2,953). Twelve hemiarthroplasties were performed for a pathologic fracture and one for rotator cuff arthropathy. Total shoulder arthroplasties were performed for the sequelae of trauma (2), rheumatoid arthritis (1), and avascular necrosis (1). Ninety-day mortality was closely associated with the underlying diagnosis. Perioperative mortality after shoulder arthroplasty for non-neoplastic conditions is low.

Clinical evaluation of aged patients who underwent surgery for femoral neck fractures -- comparative study of clinical results according to age.

The objective was to assess mortality and ambulatory ability for elderly patients over 90 years of age with femoral neck fractures treated surgically. From January 1998 to March 1999, 60 patients aged over 80 years were chosen for the study. The patients had a mean age of 87.1 years. The mean follow-up period was 12.9 months. The patients were classified into three groups according to age: group A (80-84 years old), group B (85-89 years old) and group C (over 90 years old). The rates of recovered postoperative walking ability were 72.2% (13/18) of group A, 65.2% (15/23) of group B and 84.2% (16/19) of group C. These patients were followed up until death or for at least one year. The overall mortality rates were 11.1% (2/18) of group A, 17.4% (4/23) of group B and 10.5% (2/19) of group C.

The Norwegian Arthroplasty Register: 11 years and 73,000 arthroplasties.

In 1985, the Norwegian Orthopaedic Association decided to establish a national hip register, and the Norwegian Arthroplasty Register was started in 1987. In January 1994, it was extended to include all artificial joints. The main purpose of the register is to detect inferior results of implants as early as possible. All hospitals participate, and the orthopedic surgeons are supposed to report all primary operations and all revisions. Using the patient's unique national social security number, the revision can be linked to the primary operation, and survival analyses of the implants are done. In general, the survival analyses are performed with the Kaplan-Meier method or using Cox multiple regression analysis with adjustment for possible confounding factors such as age, gender, and diagnosis. Survival probabilities can be calculated for each of the prosthetic components. The end-point in the analyses is revision surgery, and we can assess the rate of revision due to specific causes like aseptic loosening, infection, or dislocation. Not only survival, but also pain, function, and satisfaction have been registered for subgroups of patients. We receive reports about more than 95% of the prosthesis operations. The register has detected inferior implants 3 years after their introduction, and several uncemented prostheses were abandoned during the early 1990s due to our documentation of poor performance. Further, our results also contributed to withdrawal of the Boneloc cement. The register has published papers on economy, prophylactic use of antibiotics, patients' satisfaction and function, mortality, and results for different hospital categories. In the analyses presented here, we have compared the results of primary cemented and uncemented hip prostheses in patients less than 60 years of age, with 0-11 years' follow-up. The uncemented circumferentially porous- or hydroxyapatite (HA)-coated femoral stems had better survival rates than the cemented ones. In young patients, we found that cemented cups had better survival than uncemented porous-coated cups, mainly because of higher rates of revision from wear and osteolysis among the latter. The uncemented HA-coated cups with more than 6 years of follow-up had an increased revision rate, compared to cemented cups due to aseptic loosening as well as wear and osteolysis. We now present new findings about the six commonest cemented acetabular and femoral components. Generally, the results were good, with a prosthesis survival of 95% or better at 10 years, and the differences among the prosthesis brands were small. Since the practice of using undocumented implants has not changed, the register will continue to survey these implants. We plan to assess the mid- and long-term results of implants that have so far had good short-term results.

Early mortality after cervical hip fractures.

A total of 59 (13.5 per cent) of 437 patients with cervical hip fractures died within the first 3 months, compared with an expected mortality rate of 2.6 per cent in the comparable general population (P < 0.05). The average age at death was 86 years (range, 62-98). The 3-months mortality rate among patients admitted from institutions was 24/105 = 23 per cent compared with 35/332 = 10.5 per cent for patients admitted from their own homes (P < 0.05). The 3-months mortality rate for patients with Garden 1 + 2 fractures was 9.4 per cent compared with 14 per cent for Garden 3 + 4 (P < 0.05). This series seems to suggest that non-cemented hemi-arthroplasty may be associated with an increased 3-months mortality rate of 21 per cent compared with 13.9 per cent (P < 0.05) for patients with the same age distribution. This may be due to a relatively high deep-infection rate following non-cemented hemi-arthroplasty.

Bateman bipolar hemiarthroplasty for displaced intracapsular femoral neck fractures. Uncemented versus cemented.

Four hundred forty-seven patients with 451 displaced fractures of the femoral neck were treated with Bateman bipolar hemiarthroplasty (190 cemented and 261 uncemented) between 1985 and 1990 in the authors' institution. During a follow-up period of at least two years, the authors found less thigh pain (13% versus 46.2%) and higher Harris hip scores (86 versus 79) in the cemented group in comparison with the uncemented group. Radiographic examination showed less radiolucent zones and subsidence in the cemented group. Heterotopic ossification was more common in the cemented group. Despite the fact that the cemented group had longer operative times (average, 20 minutes) and more blood loss (average, 160 ml) during the operation, there was no significant difference in the early mortality rate observed between these two groups. The cemented prostheses provided better functional and radiographic results and fewer failures in the early stage. In addition, the cemented prostheses did not lead to more complications and higher mortality rates. Thus, for elderly patients who need early ambulation and functional recovery, the cemented Bateman bipolar prosthesis appears to be a better choice than the uncemented Bateman prosthesis.