Neutrophil-Lymphocyte Ratio and Lymphocyte-Monocyte Ratio correlate with Chronic Prosthetic Joint Infection but are not useful markers for diagnosis.

PURPOSE: To investigate reported correlations between Neutrophil-to-Lymphocyte (NLR) and Lymphocyte-to-Monocyte (LMR) ratios and their value in diagnosis of chronic prosthetic joint infection (PJI) in a large cohort of patients from a single specialist hospital. METHODS: Diagnostic aspirations of 362 patients under investigation for PJI were identified. Of the included patients 185 patients received a final diagnosis of PJI and 177 were classed as aseptic. Established criteria (ICM 2018) were employed to define PJI. Included in the analysis are differential white cell counts, C-Reactive Protein (CRP), Synovial Leukocyte Count, Synovial Alpha-defensin ELISA and Synovial Leukocyte esterase activity. Receiver-operator characteristic (ROC) curves were calculated for each of the available diagnostic tests together with the corresponding area under the curve values (AUC). Youden's index was utilized to identify the optimal diagnostic threshold point for the NLR and LMR. Other diagnostic tests were evaluated as per the threshold values previously defined in the literature and specified in the ICM criteria. RESULTS: Using Youden's Index to identify the optimal NLR cut-off within our cohort we established a value of 2.93. This yielded a sensitivity of 0.60 and specificity of 0.64. The area under the curve (AUC) of a receiving operator characteristics (ROC) curve was 0.625. Regarding the LMR the results demonstrate similar findings; a positive correlation with a diagnosis of infection but poor sensitivity and specificity. The AUC for LMR was 0.633 and was not superior to NLR (P = 0.753). CONCLUSIONS: There is a significant correlation between higher Neutrophil-Lymphocyte and Lymphocyte-Monocyte ratios, and a diagnosis of PJI. The sensitivity and specificity of this calculation is poor and the does not add value to the diagnostic algorithm for PJI. LEVEL OF EVIDENCE: Level III Retrospective Cohort analysis.

Outcome of surgically treated acetabular fractures: risk factors for postoperative complications and for early conversion to total hip arthroplasty.

INTRODUCTION: The gold standard of Acetabular fractures treatment is open reduction and internal fixation (ORIF). Our purpose is to assess the short- to medium-term outcomes and complications of surgically treated acetabular fractures. We analysed factors influencing clinical outcomes, incidence of complications and predictors of conversion in total hip arthroplasty (THA). MATERIALS AND METHODS: We retrospectively analysed 102 patients with acetabular fracture surgically treated between December 2017 and September 2020. We evaluated the quality of reduction with x-ray measuring residual displacement, classified into 3 groups (Matta Radiological Score). At the final follow-up, radiographs were graded according to Matta's Radiological Outcome Grading, and the clinical outcomes were graded using Oxford Hip Score (OHS). RESULTS: 62 patients were enrolled. OHS was influenced by quality of reduction (p = 0.031), injury severity score (ISS) (p = 0.003) and BMI > 30 (p < 0.0001). The late sequelae were heterotopic ossification (HO) in 13 patients, osteoarthritis (OA) in 22 and avascular necrosis (AVN) in 4. HO was significantly affected by posterior approach and ISS > 15. The analysis showed a correlation between AVN and posterior hip dislocation. OA had a correlation with postoperative quality of reduction (p = 0.014). Eight patients required THA with a significant correlation between THA and posterior dislocation, isolated posterior wall fracture and ISS > 15. CONCLUSION: A high rate of patients with acetabular fractures still develop complications and require THA. Identification of predictors for poor outcome may help to inform surgical decision-making regarding options of plate osteosynthesis or 'Fix and Replace', to avoid poor outcomes and early revision surgery.

Treatment Strategies and Outcomes for Osteochondritis Dissecans of the Capitellum.

BACKGROUND: The optimum management of osteochondritis dissecans (OCD) of the capitellum is a widely debated subject. PURPOSE: To better understand the efficacy of different surgical modalities and nonoperative treatment of OCD as assessed by radiological and clinical outcomes and return to sports. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic review of all treatment studies published between January 1975 and June 2020 was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A total of 76 clinical studies, including 1463 patients, were suitable for inclusion. Aggregate analysis and subgroup analysis of individual patient data were performed to compare the functional and radiographic outcomes between the various nonoperative and surgical treatment options for capitellar OCD. A unified grading system (UGS; grades 1-4) was developed from existing validated classification systems to allow a comparison of patients with similar-grade OCD lesions in different studies according to their treatment. Patient-level data were available for 352 patients. The primary outcome measures of interest were patient-reported functional outcome, range of motion (ROM), and return to sports after treatment. The influences of the capitellar physeal status, location of the lesion, and type of sports participation were also assessed. Each outcome measure was evaluated according to the grade of OCD and treatment method (debridement/microfracture, fragment fixation, osteochondral autograft transplantation [OATS], or nonoperative treatment). RESULTS: No studies reported elbow scores or ROM for nonoperatively treated patients. All surgical modalities resulted in significantly increased postoperative ROM and elbow scores for stable (UGS grades 1 and 2) and unstable lesions (UGS grades 3 and 4). There was no significant difference in the magnitude of improvement or overall scores according to the type of surgery for stable or unstable lesions. Return to sports was superior with nonoperative treatment for stable lesions, whereas surgical treatment was superior for unstable lesions. Patients with an open capitellar physis had superior ROM for stable and unstable lesions, but there was no correlation with lesion location and the outcomes of OATS versus fragment fixation for high-grade lesions. CONCLUSION: Nonoperative treatment was similar in outcomes to surgical treatment for low-grade lesions, whereas surgical treatment was superior for higher grade lesions. There is currently insufficient evidence to support complex reconstructive techniques for high-grade lesions compared with microfracture/debridement alone.

Modelling the effect of a dedicated hip fracture unit on patient outcomes using segmented robust linear regression techniques.

INTRODUCTION: Typically, a healthcare intervention is evaluated by comparing data before and after its implementation using statistical tests. Comparing group means can miss underlying trends and lead to erroneous conclusions. Segmented linear regression can be used to reveal secular trends but is susceptible to outliers. We described a novel method using segmented robust regression techniques to evaluate the effect of introducing a dedicated hip fracture unit (HFU). METHODS: We retrospectively analysed patient outcomes from a total of 2777 patients sustaining proximal femoral fragility fractures over a 6-year period at a Level 1 Major Trauma Centre. We compared time to surgical intervention and length of hospital stay before and after the implementation of the HFU using group comparison tests, segmented ordinary regression and robust regression techniques to evaluate the effect of the intervention. RESULTS: Group comparison tests did not identify a significant difference in time to surgery pre and post- HFU. Segmented regression revealed that there was a significant reduction in time to surgery but that this predated the introduction of the HFU. Group comparison tests did not identify a significant difference in length of stay pre and post-HFU. Ordinary segmented regression demonstrated that there was a constant reduction in length of stay, which accelerated after the introduction of the HFU. Robust regression identified that this change occurred prior to the HFU. DISCUSSION: There was a significant decrease in time to surgical intervention during the study period that occurred long before the introduction of the HFU, and that cannot be attributed to the HFU itself. Length of stay started dropping early in the study period and was unrelated to the HFU. However, with robust regression we concluded that the HFU was effective in reducing relatively long hospital stays (outliers). Several explanatory factors that may have affected the observed trends in time to surgery and length of stay were identified. CONCLUSION: Robust regression is a useful adjunct to ordinary segmented linear regression techniques in modelling retrospective time-series and dealing with outliers. The changes observed in hip fracture patient outcomes over a 6-year period was likely multifactorial.

Knee dislocation and associated injuries: an analysis of the American College of Surgeons National Trauma Data Bank.

PURPOSE: Knee dislocations (KDs) are potentially devastating injuries, leading to loss of function or limb in often young patients. This retrospective database review aims to determine the relative incidence and risk factors for KDs presenting to North American Level I and II trauma centers. METHODS: The National Trauma Data Bank (NTDB) was retrospectively interrogated using ICD-9-CM codes to identify KDs between 2010 and 2014 to derive KD incidence. KDs were stratified by age, sex, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), drug and alcohol use, injury mechanism, open vs. closed KD, vascular injury and fracture. Each co-variate was tested against different mechanisms of injury, using Chi-squared tests and risk adjusted analyses to derive risk factors for KD. The same calculations were done for secondary outcomes (vascular and neurological injuries, compartment syndrome, amputation, and mortality). RESULTS: A total of 6454 KDs met the inclusion criteria (18/10,000 admissions). KDs occurred most commonly amongst men, aged 20-39, with an ISS score 1-14 and following motor vehicle collision (MVC). A vascular investigation was performed in 29%, with injury documented in 15% of KDs and 10.8% receiving a vascular procedure. Associated fractures were observed in 41.4% of KDs. Open injuries in 13.6%. Neurological injury documented in 6.2%, compartment syndrome in 2.7%, amputation in 3.8% (> 50% had vascular injury) and 2.8% died. MVC was the most common mechanism of injury (p < 0.001), significantly more common in young, male patients, associated with higher ISS and lower GCS, especially when drugs or alcohol were involved (p < 0.0001). Being male, having a vascular injury or open KD were all risk factors for compartment syndrome, amputation and neurological injuries. CONCLUSIONS: KDs are rare injuries, but their relative incidence may be increasing. Young, male patients involved in MVCs are risk factors for KDs and their associated injuries, such as neurological injuries, amputations and compartment syndrome. Vascular injury occurs at a frequency of around 15%. The findings of the current study may guide future research and help to inform clinicians on the expected rates of associated injuries in patients identified to have KD in a trauma center population. It informs regarding risk factors for KD, which may improve diagnosis rates of spontaneously reduced knee dislocations by increasing index of suspicion in high-risk patients and identifies specific links with impaired driving. LEVEL OF EVIDENCE: IV.

Femoral Shaft Fracture during Bungee Jump: A Case Report and Literature Review.

Bungee jumping is a recreational sport that is accepted to carry a level of risk. We present the case of a femoral fracture sustained during bungee jumping and examine the published literature on bungee jumping-related injuries. A previously well 31-year old female performed a 200ft bungee jump from a crane. The apparatus was performed as expected and documented on the bystander video footage. As the bungee-cord became taut for the second time, there was an audible crack with accompanying scream. A closed, neurovascularly-intact injury was sustained to her right thigh. Radiographs revealed a comminuted mid-diaphyseal spiral femoral fracture, which was treated with intra-medullary nail fixation the following day. Following loss of position with proximal fragment flexion, the intramedullary nail was revised with open reduction and cerclage wiring 6 weeks later. Progression to clinical and radiological union was uneventful. Fatalities in bungee jumping are generally secondary to trauma as a result of equipment malfunction, user error, or related to pre-existing co-morbidity2. As no records are kept on bungee jumping injuries in the UK, reliable statistics are not available regarding the relative risks of this sport. We conclude that incidence of bungee jumping injuries is likely to remain low, but consider that improved recording of bungee jumping-related injury data will allow providers to give customers a realistic quantification of risk before engaging in this sport.