Significant deterioration in quality of life and increased frailty in patients waiting more than six months for total hip or knee arthroplasty : a cross-sectional multicentre study.

AIMS: The primary aim of this study was to assess whether patients waiting six months or more for a total hip (THA) or knee (KA) arthroplasty had a deterioration in their health-related quality of life (HRQoL). Secondary aims were to assess changes in frailty and the number of patients living in a state considered to be worse than death (WTD), and factors associated with changes in HRQoL and frailty. METHODS: This cross-sectional study included 326 patients, 150 males (46.0%) and 176 females (54.0%), with a mean age of 68.6 years (SD 9.8) who were randomly selected from waiting lists at four centres and had been waiting for six months or more (median 13 months, interquartile range 10 to 21) for a primary THA (n = 161) or KA (n = 165). The EuroQol five-dimension questionnaire (EQ-5D) and visual analogue scores (EQ-VAS), Rockwood Clinical Frailty Scale (CFS), and 36-Item Short Form Survey subjective change in HRQoL were assessed at the time and recalled for six months earlier. A state that was WTD was defined as an EQ-5D of less than zero. RESULTS: There were significant deteriorations in the EQ-5D (mean 0.175, 95% confidence interval (CI) 0.145 to 0.204; p < 0.001), EQ-VAS (mean 8.6, 95% CI 7.0 to 10.4; < 0.001), and CFS (from 3 "managing well" to 4 "vulnerable"; p < 0.001), and a significant increase in the number of those in a state that was WTD (n = 48; p < 0.001) during the previous six months for the whole cohort. A total of 110 patients (33.7%) stated that their health was much worse and 107 (32.8%) felt it was somewhat worse compared with six months previously. A significantly greater EQ-5D (-0.14, 95% CI 0.08 to 0.28; p = 0.038) and a state that was not WTD (-0.14, 95% CI 0.01 to 0.26; p = 0.031) were associated with a deterioration in the EQ-5D. THA (0.21, 95% CI 0.07 to 0.34; p = 0.002) or a lower (better) CFS (0.14, 95% CI 0.07 to 0.20; p < 0.001) were independently significantly associated with a deterioration in the CFS. CONCLUSION: Patients waiting more than six months for THA or KA had a significant deterioration in their HRQoL and increased frailty, with two-thirds of patients feeling that their health had worsened.Cite this article: Bone Joint J 2022;104-B(11):1215-1224.

IMPACT-Scot report on COVID-19 and hip fractures.

AIMS: The primary aim was to assess the independent influence of coronavirus disease (COVID-19) on 30-day mortality for patients with a hip fracture. The secondary aims were to determine whether: 1) there were clinical predictors of COVID-19 status; and 2) whether social lockdown influenced the incidence and epidemiology of hip fractures. METHODS: A national multicentre retrospective study was conducted of all patients presenting to six trauma centres or units with a hip fracture over a 46-day period (23 days pre- and 23 days post-lockdown). Patient demographics, type of residence, place of injury, presentation blood tests, Nottingham Hip Fracture Score, time to surgery, operation, American Society of Anesthesiologists (ASA) grade, anaesthetic, length of stay, COVID-19 status, and 30-day mortality were recorded. RESULTS: Of 317 patients with acute hip fracture, 27 (8.5%) had a positive COVID-19 test. Only seven (26%) had suggestive symptoms on admission. COVID-19-positive patients had a significantly lower 30-day survival compared to those without COVID-19 (64.5%, 95% confidence interval (CI) 45.7 to 83.3 vs 91.7%, 95% CI 88.2 to 94.8; p < 0.001). COVID-19 was independently associated with increased 30-day mortality risk adjusting for: 1) age, sex, type of residence (hazard ratio (HR) 2.93; p = 0.008); 2) Nottingham Hip Fracture Score (HR 3.52; p = 0.001); and 3) ASA (HR 3.45; p = 0.004). Presentation platelet count predicted subsequent COVID-19 status; a value of < 217 × 109/l was associated with 68% area under the curve (95% CI 58 to 77; p = 0.002) and a sensitivity and specificity of 63%. A similar number of patients presented with hip fracture in the 23 days pre-lockdown (n = 160) and 23 days post-lockdown (n = 157) with no significant (all p ≥ 0.130) difference in patient demographics, residence, place of injury, Nottingham Hip Fracture Score, time to surgery, ASA, or management. CONCLUSION: COVID-19 was independently associated with an increased 30-day mortality rate for patients with a hip fracture. Notably, most patients with hip fracture and COVID-19 lacked suggestive symptoms at presentation. Platelet count was an indicator of risk of COVID-19 infection. These findings have implications for the management of hip fractures, in particular the need for COVID-19 testing. Cite this article: Bone Joint J 2020;102-B(9):1219-1228.

Radiographic Correction Following Reconstruction of Adult Acquired Flat Foot Deformity Using the Cotton Medial Cuneiform Osteotomy.

BACKGROUND: The Cotton osteotomy has been used to correct residual forefoot supination in flexible flatfoot deformity reconstruction. The purpose of this study was to delineate the radiographic effects of the Cotton osteotomy by controlling for concomitant procedures used for deformity correction. METHODS: We retrospectively analyzed 67 patients who underwent a Cotton osteotomy as part of a flatfoot reconstructive procedure. We evaluated 12 radiographic parameters including the articular surface angles of the foot, Meary angle, and a newly defined medial arch sag angle (MASA). Twenty-eight of these patients were matched to a cohort that did not undergo a Cotton osteotomy. RESULTS: In all patients who underwent a Cotton osteotomy, there were statistically significant changes in the articular surface angles and medial arch height (P < .05). No radiographic secondary sag of the medial column was seen at final follow-up. Compared to 28 matched controls, the Cotton osteotomy did not improve Meary angle but provided an additional 6.5 degrees correction of the MASA (P = .002). After reliability testing, the intraclass correlation coefficient was found to be substantial for the MASA compared to Meary angle. DISCUSSION: The data suggest that the MASA was a useful radiographic tool for assessing midfoot collapse in the setting of pes planovalgus. The current study demonstrated the corrective capacity of the Cotton osteotomy on the MASA; at final follow-up, there was no evidence of radiographic instability. This is suggestive that a naviculocuneiform arthrodesis may not be warranted for medial column stabilization in the setting of flatfoot reconstruction. LEVEL OF EVIDENCE: Level III, case control study.

Is the Stryker Revolution mixing system fit for purpose? Reliability and a micro-CT assessment of cement porosity.

The Stryker Revolution(TM) is a new mixing system that employs a high vacuum and a motorised mixing spatula in an effort to reduce cement porosity. We have compared Revolution(TM) with Depuy Cemvac(®), in terms of system reliability and cement porosity. Standardised Simplex P(®) and SmartSet(®) HV cement samples were produced using both mixing systems and analysed using a micro-CT scanner. The overall porosity, number and volume of voids were measured. Void analysis was subdivided into macro-pores (>0.5 mm3) and micro-pores (0.0005-0.5 mm3). Both systems were easy to use and no breakages were encountered. There was no significant difference in overall porosity between Revolution(TM) and Cemvac(®). Revolution(TM) produced over a five-fold decrease in average macro-pore size with medium viscosity cement (p=0.02), but produced a greater number of micro-pores (p<0.01). SmartSet(®) HV specimens had a higher porosity compared to Simplex P(®). This study demonstrated that the Revolution(TM) system was reliable and reduced porosity at least as effectively as the established Cemvac(®) system. The Revolution(TM) produced a greater number of smaller pores and further testing is required to establish if this results in a significant mechanical benefit.

In vitro comparison of Refobacin-Palacos R with Refobacin Bone Cement and Palacos R + G.

BACKGROUND: Refobacin Palacos R (RPR) is no longer produced and Palacos R + G (PRG) and Refobacin Bone Cement R (RBC) have been introduced to supersede it. We performed an in vitro study to ascertain whether the handling and mechanical properties of the more recent cement preparations are different to those of their predecessor. METHODS: The 3 cements were tested to ISO 5833 and German DIN 53435 standards. In addition, their gentamicin elution, shrinkage, viscosity, and handling characteristics were studied. RESULTS: All 3 cements had comparable mechanical properties exceeding the ISO 5833 and DIN 53435 standards. They eluted similar amounts of gentamicin and had comparable shrinkage. In the batches tested, RBC showed statistically significantly longer handling curves. Both PRG and RBC had statistically significantly lower viscosities as they cured compared to their predecessor. INTERPRETATION: Surgeons must be aware that both successor cements do not appear to have handling curves and viscoelastic properties identical to those of RPR.

Inter- and intra-batch variability in the handling characteristics and viscosity of commonly used antibiotic-loaded bone cements.

BACKGROUND: Several factors can affect the viscosity of a cement and therefore its handling characteristics. We performed an in vitro study to ascertain whether anecdotal observations of differences in handling between batches of the same brand of cement actually existed. METHODS: 3 batches of Simplex P Tobramycin (SPT), Refobacin Bone Cement (RBC), SmartSet GHV (SSG) and Palacos R+G (PRG) were tested. 6 replicates of each batch were vacuum-mixed and their viscosity in relation to time was measured under laboratory conditions using a rheometer. We examined the handling characteristics of 6 replicates of each batch after they were hand-mixed under theater conditions. RESULTS: Inter- and intra-batch variability was seen in the viscosity of all brands of cement tested. Interbatch calculations were influenced by high intra-batch variability in viscosity. The viscosity of RBC cement was similar to that of SSG, but different to that of PRG (p = 0.01 at 5 N and p = 0.009 at 40 N). INTERPRETATION: Our results suggest that in clinical practice, extrinsic factors such as preparation conditions and methods probably play a more important role than the intrinsic variability of cements. However, variability in handling and viscosity will exist in all brands of cement prepared under theater conditions and the surgeon must be aware of why they may act differently.