Comparative analysis of geriatric hip fracture management outcomes in teaching and nonteaching hospitals in Jordan.

Hip fractures are common orthopedic injuries that have significant impacts on patients and healthcare systems. Previous studies have shown varying outcomes for hip fracture management in different settings, with diverse postoperative outcomes and complications. While teaching hospital settings have been investigated, no studies have specifically examined hip fracture outcomes in teaching hospitals in Jordan or the broader Middle East region. Therefore, the aim of this study was to investigate this important outcome. A cohort comprising 1268 patients who underwent hip fracture fixation from 2017 to 2020 was analyzed for nine distinct outcomes. These outcomes encompassed time to surgery, ICU admissions, perioperative hemoglobin levels, length of hospital stay, readmission rates, revision procedures, and mortality rates at three time points: in-hospital, at 6-months, and at 1-year post-surgery. The analysis of 1268 patients (616 in teaching hospitals, 652 in non-teaching hospitals) showed shorter mean time to surgery in teaching hospitals (2.2 days vs. 3.6 days, p < 0.01), higher ICU admissions (17% vs. 2.6%, p < 0.01), and more postoperative blood transfusions (40.3% vs. 12.1%, p < 0.01). In-hospital mortality rates were similar between groups (2.4% vs. 2.1%, p = 0.72), as were rates at 6-months (3.1% vs. 3.5%, p = 0.65) and 1-year post-surgery (3.7% vs. 3.7%, p = 0.96). Geriatric hip fracture patients in teaching hospitals have shorter surgery times, more ICU admissions, and higher postoperative blood transfusion rates. However, there are no significant differences in readmission rates, hospital stays, or mortality rates at various intervals.

Effect of Preoperative Antianxiety Medications on Blood Pressure and Blood Loss in Total Knee Arthroplasty: A Case-Control Study.

Background: The increasing number of canceled operations in patients undergoing total knee arthroplasty (TKA) due to high blood pressure readings has put a considerable burden on surgeons. In this study, we aim to assess the effect of giving antianxiety drugs preoperatively on maintaining blood pressure (BP) and blood loss for patients undergoing TKA surgery. Methods: This retrospective case-control study included patients who underwent total knee arthroplasty and divided them into two main groups: those who had taken a 3 mg bromazepam oral tablet at the night preoperatively and the control group. The blood pressure of patients was then measured preoperatively (baseline), in the morning of surgery, in the operating room before anesthesia, and during the surgery. The percentage of measured BP was calculated by dividing the measured BP by the baseline, then multiplying by 100. Results: 301 patients were included in our study: 137 received bromazepam and 164 as a control group. The ratio of systolic BP (SBP) in the morning of surgery to the baseline (percentage of morning SBP) decreased significantly in the bromazepam group compared with the controls. The ratio of SBP, in the operating room before anesthesia (percentage of preanesthesia SBP) also decreased significantly in the bromazepam group. However, the percentage of SBP in the middle of surgery did not change significantly. In addition, there was a significant difference change from the baseline in diastolic BP and mean arterial BP between the two groups in the morning of surgery, inside the theatre, and in the middle of the operation. The bromazepam group also showed a significant decrease in blood loss. Conclusion: Preoperative oral antianxiety drugs (bromazepam) helps in controlling hemodynamic changes associated with anxiety, including maintaining BP in well-controlled hypertensive and healthy patients undergoing TKA, and it plays a role in decreasing the total blood loss.

Staples versus sutures wound closure in hip and knee arthroplasty: a prospective cohort study.

OBJECTIVE: This study aimed to compare two methods of wound skin closure-staples versus vertical mattress nylon sutures-in patients undergoing primary total hip (THR) and total knee replacements (TKR). The comparison was for wound complications as a primary outcome, and satisfaction of patient and nurse as secondary outcomes. METHOD: A prospective cohort study was conducted at an academic teaching hospital. All the patients who were admitted for either primary THR or TKR from September 2018 to September 2019 were included. Revision surgeries, patients >85 years of age, and those who were on steroid therapy were excluded. Patients were divided into two groups (staples and sutures) to compare the two methods of wound closure. Patients in each group were assessed for characteristics such as age, sex, weight, height, comorbidities, smoking status, postoperative wound complications, reoperation and patient/nurse satisfaction. RESULTS: A total of 100 patients met the inclusion criteria. In the staples group (n=50), 26 patients underwent THR while 24 patients underwent TKR. In the sutures group (n=50), 23 patients underwent THR and 27 patients underwent TKR. Overall, there was no significant difference between the two groups (staples versus sutures) in terms of wound complications (p=0.401), patient satisfaction (p=0.357) and nurse satisfaction (p=0.513). Further analysis compared THR and TKR subgroups (THR staples versus THR sutures and TKR staples versus TKR sutures). The results showed no significant difference between the staples and sutures subgroups of THR and TKR in terms of wound complications, patient satisfaction and nurse satisfaction. CONCLUSION: In THR and TKR, there was no significant difference between either vertical mattress nylon sutures or staples primary skin closure in terms of wound complications and patient satisfaction in this study. The decision on wound closure method should be based on the availability of resources in the institution/country.

Presentation of a large pseudoaneurysm of the brachial artery: A case report.

Brachial artery pseudoaneurysms (PSA) are considered uncommon, but they can be limb and life threatening. Most etiologies are related to iatrogenic injury or following a fracture. Here we present a 37-year-old male complaining of a large swelling in his right upper arm that was gradually increasing in size for the last 7 months. It started with a sudden onset of pain while lifting heavy boxes at his daily job. Ultrasound and MRA showed a pseudoaneurysm of the right brachial artery. Resection of the PSA was performed with a vein interposition graft. This case illustrates the significance of considering PSA as a differential diagnosis in patients presenting with upper arm swelling without history of obvious trauma.

Characteristics of Elderly Hip Fracture Patients in Jordan: A Multicenter Epidemiological Study.

Background: Elderly hip fractures represent a global health care burden. Several reports expected a massive increase in the incidence of hip fractures by the next few decades. Knowing the epidemiology of hip fractures is crucial for planning health care policies. The purpose of this study is to provide a nationwide epidemiological overview of hip fractures in Jordan and to report the perioperative outcomes that may help to improve the delivered healthcare. . Methods: We conducted a retrospective study at 2 university hospitals and 2 major governmental hospitals in Jordan. We reviewed the records for all patients (age >55 years) who were diagnosed with hip fractures over a 3 years duration (2019-2021). We documented the patient's characteristics and the perioperative data (including preoperative, intraoperative, and postoperative details including the 1-year mortality). . Results: The total number of included patients was 1268; more than half (53.7%) were females. The mean age is 75 years (SD 9.7). The most common fracture type was trochanteric (66.2%) . 7% of patients had a prior contralateral hip fracture . The average time from admission to surgery was 2.96 days (SD 2.63). The surgery was done within 48 hours for 56.7% of patients. Approximately, one-third of all patients (34.5%) received a blood transfusion. The average length of hospital stay is 7.44 days (SD 5). The overall rate of postoperative thromboembolic events, readmission within 1 month, and revision for the same surgery are 2.4% , 10.7% , and 3% respectively. The 1-month, 6-month, and 12-month mortality rates are 4.5%, 9.1%, and 12.8% respectively. Conclusion: The annual incidence of elderly hip fractures in Jordan is approximately 96 per 100,000 individuals. The 1-year mortality rate of hip fractures in Jordan is 12.8% . Both findings are in the lower range of nearby Arab countries.

Perceptions and performance of exercise in people with knee osteoarthritis in the Middle East: are they different to countries in the developed world? A qualitative study in Jordan.

Background: Culture and lifestyle could justify the variability in clinical patterns of knee osteoarthritis (OA) and was reported to affect exercise adherence.Objective: To explore perceptions and aspects influencing exercise adherence in people with knee OA in Jordan (a developing country) as they might be different from those reported in the developed world.Methods: Fourteen participants were included in the study (13 females, one male). One focus group and seven in depth semi-structured interviews were conducted. The discussions were audio-taped and transcribed. Framework analysis was used and data were interpreted using the socio-ecological model.Results: At the individual level, knowledge of the role of exercise in knee OA and personal factors influenced exercise performance and adherence. At the sociocultural level, cultural attitudes and beliefs and social interaction affected exercises adherence. At the organizational/political level, suboptimal service delivery process, inappropriate delivery of home exercises, accessibility of services affected exercise adherence. Opportunities for improving service delivery were also reported. At the environmental level, geography and weather affected adherence.Conclusions: Understanding the interaction of health-related behavior with individual, social/cultural, organizational, and environmental aspects would improve exercise adherence and equip physiotherapists with knowledge and resources to facilitate the implementation of patient-centered services.

The Surgical Management of the Rare Neurogenic Myositis Ossificans of the Hip: A Report of 3 Cases.

INTRODUCTION: Myositis ossificans (MO) is a benign non-neoplastic condition in which heterotopic bone formation occurs in soft tissues. Neurogenic MO is one variant of MO where the lesion is a result of neurological disorders, including brain and spinal cord injuries, especially when followed by immobility and spasticity. MO can also be a result of direct trauma or even genetic mutations. CASE REPORT: We present three cases of young men (16, 37, and 22-year-old) who developed MO of the hip joint following brain or spinal cord injuries. One of them had also sustained a direct trauma to the affected hip joint at the time of the accident. All three patients presented with inability to walk independently due to diminished range of motion at the affected joint. X-rays and computerized tomography (CT) scans with 3-dimentional (3D) reconstruction suggested the diagnosis of MO, but the serum alkaline phosphatase was within normal limits at the time of presentation. The first case had bilateral involvement with unmistakable separation between the heterotopic bone formation and the frank hip joints on CT. This patient underwent successful staged excision of the ossifications. The second patient had unilateral hip joint involvement with the absence of clear separation between the heterotopic bone formation and the hip joint, thus, underwent total hip replacement for the affected side as excision was not possible. The third patienthad unilateral hip joint involvement and underwent excision of the ossification with dynamic hip screw insertion after sustaining a stable intertrochanteric fracture intraoperatively. Postoperatively, all three patients received physiotherapy and oral indomethacin. Upon recovery, they were able to walk independently with a near-normal range of motion at the hip joint. There was no evidence of recurrence upon follow-up visits, and CT scans in patients I and II. Follow-ups for patient III were not possible as the patient died 1 month after surgery due to pulmonary embolism. CONCLUSION: The surgical management of MO is indicated when non-operative methods fail to provide an adequate range of motion around the hip joint. Pre-operative assessment utilizing 3D-CT scans proved to be essential in dictating the appropriate surgical approach. During post-operative follow-ups, the physiotherapy and oral indomethacin provided additional improvement in outcome and patients' satisfaction.

A Rare Case of Intra-articular Osteochondroma of the Femoral Neck: A Case Report.

INTRODUCTION: The osteochondroma (OC) is considered a benign tumor with long bone preference. It presents usually at the metaphyseal part of the bone, with rare cases of intra-articular origins especially in the hip joint. The presentation of such rare cases varies according to its site and mass effect, which may compress the adjacent nerves, tendon, or vascular structures.The femoral neck OC carries a higher risk of femoral head vascular injury and necrosis, as well as sciatic nerve injury, which requires careful preoperative planning and intraoperative cautions. We report a rare case of intra-articular OC in the hip. CASE REPORT: A 28-year-old male, presented to our hospital, with complaints of right-side gluteal pain, decrease hip joint extension, and feeling of a hard mass for 2 years. The radiographic evaluation showed an osseous mass related posterior and inferior to the right femur neck, with cortical and medullary continuation, and cartilaginous cap on the magnetic resonance image. The suspicious was OC, and planned for excision and histopathological evaluation. The excision was done through lateral hip approach, and it was intra-articular with marked stretching of the joint capsule. Complete excision was done, as close as possible to the femoral neck cortex using saw and osteotomes, followed by prophylactic fixation using two cannulated screws. The histopathology reports confirm the diagnoses, and the patient started on hip range of motion and abductor strengthening exercises. Over a 4-month follow-up period the patient showed significant improvement in his hip range of motion. CONCLUSION: The intra articular OC of the hip is as rare presentation of the OC, which carries the risks of avascular necrosis as well as nerve compression. Clinical suspicion, proper planning, and histopathological evaluation are needed for better results.

Fungal Prosthetic Joint Infection Following Total Knee Arthroplasty: A Case Report.

INTRODUCTION: Prosthetic joint infection (PJI) is a rare complication of total knee replacement (TKR), yet it is a serious and debilitating condition. Bacterial infection accounts for the majority of cases and fungal infection is estimated to cause 1% of all prosthesis infection. CASE REPORT: This case presents a 60years female, who presented to our outpatient orthopedic clinic complaining of right knee pain, swelling, and hotness. The physical examination revealed redness, hotness, restricted range of movement, and tibial loosening, 9 months following TKR revision. Culture of the joint aspirate showed growth of "Candida parapsilosis" and second aspirate confirmed the diagnosis. The patient then underwent two stages revision surgery with placement of amphotericin B loaded cement, to maintain high local antifungal concentration in addition to decrease the side effects of amphotericinB infusion such as thrombophlebitis and the more serious systemic effect as nephrotoxicity. The post-operative course was uneventful, with gradual improvement and restoration of normal movement range. CONCLUSION: Fungal PJI is a rare complication of TKR, yet it results in severe debilitating symptoms and impairment of the patient functional capacity. Careful evaluation of the patient followed by a detailed workup is necessary for the identification of the underlying causative micro-organism. Two-stage revision surgery with antifungal loaded cement spacer and antifungal therapy currently is the standard of management. To the best of our knowledge, this is the first fungal PJI following total knee arthroplasty reported in Jordan.

Thermographic Assessment of Reperfusion Profile Following Using a Tourniquet in Total Knee Arthroplasty: A Prospective Observational Study.

BACKGROUND: Infrared thermal imaging is a non-invasive technique capable of detecting changes in temperature that could ultimately signify changes in blood supply. Flir One is a smartphone-based thermal camera, working by a downloadable application, capable of detecting the limb temperature through a non-contact method using infrared thermography technology. Using the Flir One camera, we will assess the lower limb reperfusion profile following the tourniquet release post total knee arthroplasty (TKA). METHODS: A prospective study included 46 patients who underwent primary TKA. We used the (Flir One Gen 3) thermographic camera to capture images at ankle joint preoperatively, and at 1, 10, and 20 minutes post tourniquet release on operation side. The contralateral ankle stands as control. RESULTS: The mean preoperative temperature (in Celsius) of ankle control side and operated side were 33.03 (SD=1.65) and 33.26 (SD=1.42), respectively. The mean ankle temperature on operation side was 19.73 (SD=2.85), 30.49 (SD=2), and 32.43 (SD=1.31) at 1, 10, and 20 minutes post tourniquet release, respectively, while the control side showed a mean temperature of 32.85 (SD=1.42), 32.84 (SD=0.91), and 33.15 (SD=0.95) at the same time intervals. There was a significant statistical difference between both ankle temperatures at 1 and 10 minutes (P=0.00 for each time). At 20 minutes, 37 ankles (80.4%) at operation side reached a temperature level similar but below the level of control side; however, the difference was not significant (P=0.692). CONCLUSION: Infrared thermography using the smartphone-connected camera is a simple, non-invasive, feasible, and reliable technology. It provides an objective measure to assess the perfusion status of the limbs. In TKA, the distal limb will reach full reperfusion status after approximately 20 minutes of tourniquet release.

Long-Term Outcomes of the Knee and Hip Arthroplasties in Patients with Alkaptonuria.

Alkaptonuria is a rare autosomal recessive metabolic disorder. It is characterized by the accumulation of homogentisic acid in the body due to a lack of enzymes that degrade it. Over time, it results in joint degeneration and eventually leads to ochronosis. Ochronosis refers to bluish-black discoloration of connective and other tissues within the body. In this study, we present 5 distinct cases diagnosed with alkaptonuria. They have undergone 8 total joint replacement surgeries (4 hips and 4 knees) within 8 years (2010-2018). All patients had an excellent outcome over several years. The follow-up period ranged from 2 to 10 years. Although none of the presented cases had intraoperative or postoperative adverse sequelae, we must take care when dealing with patients with ochronotic arthropathy. They carry a higher risk of complications than other patients with osteoarthritis disease. These complications include fractures due to fragile bone quality, muscle or tendon rupture, joint instability, and anesthesia-related complications. Total joint arthroplasty is a valid and safe option in the management of hip and knee ochronotic arthropathy.

Knowledge of Knee Osteoarthritis and Its Impact on Health in the Middle East: Are They Different to Countries in the Developed World? A Qualitative Study.

Knowledge of knee osteoarthritis (OA) and its management options affects adherence to treatment, symptoms, and function. Many sociocultural differences exist between Jordan, as a representative of the Middle East, and the developed world which might influence the knowledge of the pathology and its impact on health. Objectives. To explore the knowledge of the pathology and the experience of people diagnosed with knee OA living in Jordan. Methods. Qualitative study design using a triangulation method of both focus groups and in-depth semistructured interviews. Fourteen participants were included (13 females and one male). One focus group and seven in-depth semistructured interviews were conducted. Discussions were audiotaped and transcribed. Framework analysis was used, and data were mapped to the International Classification of Functioning, Disability and Health framework. Results. The themes are as follows: (1) body functions and structures included two subthemes: physical changes and psychological impact; (2) activity limitation and participation restriction included three subthemes: factors influencing the activities, cultural and social perspectives to activity limitation, and participation restriction; (3) personal factors included three subthemes: knowledge and personal interpretation of disease process, knowledge of management options to relief symptoms, and influence of personal factors on activity and participation; and (4) environmental factors included three subthemes: service delivery process, ineffective communication across the care pathway, and facilitators and barriers. Conclusions. Knowledge of the disease was lacking as a consequence of inappropriate service delivery and culture. Activity limitations and participation restrictions are similar in Jordan to other cultures in addition to limitations in religious, employment, and transportation activities. The results demonstrate that the effect of knee OA varies among different cultures and highlight the role of healthcare professionals worldwide in understanding the impact of culture on health. They also increase the awareness of healthcare professionals, specifically in Jordan, on the limitations in delivered services and the importance of education.

Intra-articular injection of expanded autologous bone marrow mesenchymal cells in moderate and severe knee osteoarthritis is safe: a phase I/II study.

BACKGROUND: Knee osteoarthritis (KOA) is a major health problem especially in the aging population. There is a need for safe treatment that restores the cartilage and reduces the symptoms. The use of stem cells is emerging as a possible option for the moderate and severe cases. This study aimed at testing the safety of autologous bone marrow mesenchymal stem cells (BM-MSCs) expanded in vitro when given intra-articularly to patients with stage II and III KOA. As a secondary end point, the study tested the ability of these cells to relieve symptoms and restore the knee cartilage in these patients as judged by normalized knee injury and Osteoarthritis Outcome Score (KOOS) and by magnetic resonance imaging (MRI). METHODS: Thirteen patients with a mean age of 50 years suffering from KOA stages II and III were given two doses of BM-MSCs 1 month apart totaling 61 × 106 ± 0.6 × 106 by intra-articular injection in a phase I prospective clinical trial. Each patient was followed for a minimum of 24 months for any adverse events and for clinical outcome using normalized KOOS. Cartilage thickness was assessed by quantitative MRI T2 at 12 months of follow-up. RESULTS: No severe adverse events were reported up to 24 months follow-up. Normalized KOOS improved significantly. Mean knee cartilage thickness measured by MRI improved significantly. CONCLUSION: BM-MSCs given intra-articularly are safe in knee osteoarthrosis. Despite the limited number of patients in this study, the procedure described significantly improved the KOOS and knee cartilage thickness, indicating that they may enhance the functional outcome as well as the structural component. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02118519.

Safety and Efficacy of Autologous Intra-articular Platelet Lysates in Early and Intermediate Knee Osteoarthrosis in Humans: A Prospective Open-Label Study.

OBJECTIVE: To explore the safety and benefit from intra-articular autologous platelet lysate (PL) injection in early and intermediate knee osteoarthritis. DESIGN: Open-label prospective study. SETTING: Laboratory. PATIENTS: Adult patients, aged 35 to 70 years, with a history of chronic pain or swelling on one or both knees and imaging findings (radiograph or magnetic resonance imaging) of degenerative changes in the joint of grade I or II on the Kellgren scale were included. INTERVENTIONS: Autologous PL was given in the knee joint by percutaneous intra-articular route every 3 weeks for a total of 3 injections. MAIN OUTCOME MEASURES: Response was evaluated by nonnormalized Knee Osteoarthritis and Disability Outcome Score (KOOS). RESULTS: There was a significant improvement in the 5 aspects evaluated at weeks 32 and 52 compared with baseline. Symptoms score significantly improved at weeks 32 and 52 from a mean of 11.1 at baseline to 9.0 (P < 0.0001) and 8.7 (P < 0.0001). Stiffness score significantly improved at weeks 32 and 52 from 2.2 at baseline to 1.7 (P < 0.022) and 1.6 (P < 0.016). Pain score improved at 32 weeks and at 52 weeks from a baseline of 14.2 to 9.8 (P < 0.0001) and 9.2 (P < 0.0001). Daily Living score improved from 25.0 to 18.7 at 32 weeks (P < 0.0001) and to 15.6 at 52 weeks (P < 0.0001). Sport score improved from 10.7 to 8.4 at 32 weeks (P < 0.0001) and to 8.1 at 52 weeks (P < 0.0001). CONCLUSIONS: Intra-articular PL significantly improved score of all aspects evaluated by KOOS. Platelet lysate seems to be a safe product. CLINICAL RELEVANCE: To the best of our knowledge, this is the first clinical study addressing the use of autologous PL as a treatment measure for knee osteoarthrosis (KOA). There are no studies published regarding the treatment of KOA by intra-articular injections of PL. The previous studies were on the use of platelet-rich plasma (PRP) treatment for KOA. Platelet-rich plasma use has been in place for several years, however, a standardized protocol has not yet been established. Platelet lysate represents a safe, economical, easy to prepare, and easy to apply source of growth factors in the treatment of KOA. A head-to-head study is needed to compare PRP with PL in KOA.

The clinical pattern of knee osteoarthritis in Jordan: a hospital based study.

BACKGROUND: Different clinical profiles of knee osteoarthritis (KOA) have been reported in the literature. The aim of this investigation was to describe the clinical patterns of KOA in an ethnically distinct and homogenous population that has not been widely reported. Patients with KOA were seen in outpatient rehabilitation and orthopedic clinic of Jordan University Hospital (JUH), to determine any possible association between age, BMI, radiographic severity, and pain severity. METHODS: Patients diagnosed with KOA attending an outpatient rehabilitation clinic at JUH were studied to describe their clinical characteristics. They were included based on criteria developed by the American College of Rheumatology. Detailed histories, clinical examinations and X-rays, and anthropometric data were obtained. Data analysis focused on descriptive statistics and correlations among demographic and clinical characteristics. RESULTS: The study included 214 patients with a mean age of 55.3 years (range = 30-84 years). The mean BMI was 29.5± 5.6. We found a significant moderate positive correlation between age and radiographic severity of KOA (0.435; p <. 001) and pain severity (0.383; p. <. 001). There was also a significant weak positive correlation between BMI, radiographic severity of KOA (0.242, p <. 05), and pain severity (0.266, p. <. 01). CONCLUSIONS: We concluded that in this hospital-based cohort study in Jordan, the clinical pattern of KOA is comparable to Western cultures. However, the combination of BMI and mechanical loading during everyday activities that include different religious and cultural habits and may help explain the high level of radiographic severity in our sample.

Development of a decision support system to predict physicians' rehabilitation protocols for patients with knee osteoarthritis.

To design a medical decision support system (MDSS) that would accurately predict the rehabilitation protocols prescribed by the physicians for patients with knee osteoarthritis (OA) using only their demographic and clinical characteristics. The demographic and clinical variables for 170 patients receiving one of three treatment protocols for knee OA were entered into the MDSS. Demographic variables in the model were age and sex. Clinical variables entered into the model were height, weight, BMI, affected side, severity of knee OA, and severity of pain. All patients in the study received one of three treatment protocols for patients with knee OA: (a) hot packs, followed by electrotherapy and exercise, (b) ice packs, followed by ultrasound and exercise and (c) exercise alone. The resilient back propagation artificial neural network algorithm was used, with a ten-fold cross-validation. It was estimated that the MDSS is able to accurately predict the treatment prescribed by the physician for 87% of the patients. We developed an artificial neural network-based decision support system that can viably aid physicians in determining which treatment protocol would best match the anthropometric and clinical characteristics of patients with knee OA.