Diabetes has been associated with greater risk of complications and prolonged postoperative recovery following ankle trauma. Our cohort study reviewed the operative management and outcomes of ankle fractures in diabetic adults relative to non-diabetic adults from Jan 2016–2019. Non-diabetic controls were frequency age-matched 2:1.

34 of 572 ankle fracture presentations were in diabetic patients, 32% managed non-operatively compared to 29% of the matched non-diabetic cohort. The distribution in Lauge-Hansen fracture pattern was comparable between cohorts.

Mean length of follow-up was significantly longer for diabetics (26 weeks) compared to non-diabetics (16 weeks). Post-operative wound complications (superficial wound infection, breakdown, dehiscence) occurred in 48% of the operated diabetic ankles, compared to 5% in non-diabetics (RR 8.1, 95% CI 2.5–26.4). Reoperation (RR 4.3, 95% CI 2.5–26.4, p=0.03) and non-wound complication rates (Charcot joint, mal/non-union, metalware infection) were likewise significantly higher (RR 3.9, 95% CI 1.4–10.8, p=0.008) in diabetics. Amongst diabetics alone, those with an HbA1c >69 mmol/mol (n=14, 41%) demonstrated a significantly higher rate still of non-wound complications (RR 4.3, 95% CI 1.1–18., p=0.03) with a trend towards higher wound complication rates (RR 3, 95% CI 0.52–17, p=0.13).

Poorly controlled diabetes is associated with substantially greater complication rates following ankle fracture than those with well controlled or normal blood sugar; high HbA1c > 69mmol/mol is a significant predictor of complicated follow-up. Locally we recommend management strategies that are influenced by the fracture pattern stability and the presence or absence of complicated or poorly managed diabetes.

Aims

The modern prevalence of primary tumours causing metastatic bone disease is ill-defined in the oncological literature. Therefore, the purpose of this study is to identify the prevalence of primary tumours in the setting of metastatic bone disease, as well as reported rates of pathological fracture, postoperative complications, 90-day mortality, and 360-day mortality for each primary tumour subtype.

Introduction. Recent studies of novel healthcare episode payment models, such as the Bundled Payments for Care Improvement (BPCI) initiative, have demonstrated pathways for improving value. However, these models may not provide appropriate payments for patients with significant medical comorbidities or complications. The objective of this study was to identify risk factors for exceeding our institution's target payment, the so-called “bundle busters.”. Methods. After receiving an exemption from the Institutional Review Board, we queried our institutional data warehouse for all patients (n=412) that underwent total joint arthroplasty (TJA) of the hip (n=192), knee (n=207), or ankle (n=13), and qualified for our institution's bundled payments model during the study time period (July 2015 – May 2017). Patients with medical conditions that were not well controlled or were potentially optimizable were all sent for preoperative medical optimization prior to surgery. For each 90-day episode, patient characteristics, medical comorbidities, perioperative data, and payments from the Centers for Medicare and Medicaid Services (CMS) were obtained. Episodes where Medicare payments exceeded the target payment were considered “busters”. The busters were older, and had higher comorbidity scores (all, p<0.01). Variables were summarized using descriptive statistics and risk ratios were calculated using a modified Poisson regression analysis. Results. Of the 412 patients, 123 were bundle busters (30%). There was a median institutional loss of $11,797 (IQR, $4,312 – $26,771) for the bundle busters and a median gain of $7,402 ($5,657 – $9,206) for the non-busters. Of the 32 risk factors evaluated, 11 were identified as Independent risk factors for busting the bundle (all, p<0.05). Nine of the 11 (82%) are non-modifiable risk factors and include age, disease specific diagnoses (fracture and avascular necrosis), and medical comorbidities (congestive heart failure, pulmonary circulation disorders, renal disease, cardiac arrhythmia, chronic pulmonary disease, and neurological disorder). The remaining two medical comorbidities are potentially modifiable and include diabetes with complications, and preoperative anemia. Conclusion. Though modifiable risk factors should continue to be optimized prior to TJA, as they were in this population, there are still many non-modifiable preoperative risk factors that can lead to costs exceeding the BPCI established institutional payment goal. As such, further work with payors may be needed to help fairly and appropriately consider these non-modifiable factors which result in increased costs

Aims

The aim of this study to compare 30-day survival and recovery of mobility between patients mobilized early (on the day of, or day after surgery for a hip fracture) and patients mobilized late (two days or more after surgery), and to determine whether the presence of dementia influences the association between the timing of mobilization, 30-day survival, and recovery.

Introduction: As a consequence of the rising prevalence of diabetes worldwide, an increasing proportion of diabetic THR patients may be expected in coming years. Diabetes research on postoperative complications among arthroplasty patients is limited. We evaluated the extent to which diabetes affect the revision rate due to aseptic loosening, deep infection and dislocation following total hip arthroplasty (THA). Material and Methods: We used the Danish Hip Arthroplasty Registry (DHR) to identify all primary THR patients operated on during the period from 1 January 1996 to 31 December 2005. The presence of diabetes among THA patients was identified by using The Danish National Registry of Patients and The Danish National Drug Prescription Database. We used Poisson regression analyses, to estimate relative risk (RR) and 95% Confidence Interval (CI) for patients with diabetes compared to patients without diabetes, both crude and adjusted for potentially confounding factors. Results: We identified 57 575 first primary THR patients in DHR, of which 3 278 (5.7%) were with diabetes and 54 297 (94.3%) without diabetes. An adjusted RR for revision due to deep infection of 1.45 (CI: 1.00–2.09) was found for THA diabetic patients compared to patients without diabetes. The RR was particularly high for THA patients with diabetes less than five years (RR was 1.71 (CI: 1.24–32.34), with the presence of diabetes related comorbidites prior THA (RR was 2.35 (CI: 1.39–3.98) and diabetes related complications (RR was 1.88 (CI: 1.17–3.03). Conclusion. The patient and the surgeon should be aware of the relative increased risk of revision due to deep infection following THA as compared with the risk in THA patients without diabetes

Purpose: The aim of the study was to analyze the outcome of AO cannulated screws for fractures neck of femur in patients with Diabetes mellitus. Method: Sixty-two patients aged 50 years or more (17 males & 45 females) who underwent AO screws for fracture neck of femur over seven years (1999–2005) and followed-up for a minimum of two years formed the study population. A retrospective review of data from electronic patient record (EPR), clinical coding, clinic & GP letters was made. Age, residential placement, Garden’s classification of fracture, mode of injury, associated other co morbidities, pre-admission mobilisation status, allergies, addictions and anticoagulation status details were collected. Results: The mean age of patients was 67 years (range 52–96 yrs). Eleven patients died in two years time. Forty-one patients were less than 75 years of age and 21 patients were more than 75 years of age. All the patients more than 75 years of age had undisplaced intracapsular fractures. Thirteen patients were type I and 49 patients were type II diabetic. Non-union and avascular necrosis occurred in nine (17%) & 13 (26%) patients respectively. Revision surgery in the form of total hip replacement or hemiarthroplasty were performed in 21 (41%) cases. The incidence of avascular necrosis following osteosynthesis at one year was 14%. Age, control of diabetes, postoperative complications, pre-fracture mobilization status etc. Complications like wound infection were more principally in patients who had poorly-controlled diabetes. Conclusion: Patients with diabetes mellitus have metabolic bone disease due to vasculitis. This increases the risk of complications associated with fracture fixation such as non-union, cut-through and avascular necrosis (AVN). The complications and revision surgery rate was high in patients with displaced fractures and with poorly controlled diabetes. Comorbidities like diabetes and patient’s age were also strong predictors of healing in addition to fracture configuration. Looking at very high complication and re-operation rate, our recommendation in patients with diabetes is primary hemiarthroplasty irrespective of femoral head displacement, if there age is more than 75 years

Wound complication including superficial infection is a concern after total knee arthroplasties (TKA) in diabetics. However, influence of glycoregulation before TKA has not been investigated in relationship to wound healing. Our hypothesis was that glycated hemoglobin (HbA1C), since it reflects long-term regulation of blood glucose, might be associated with incidence of wound complications after TKA in diabetic patients. We retrospectively reviewed 167 TKAs performed in 115 patients with diabetes mellitus between January 2001 and March 2007. All patients were diagnosed as type II DM and osteoarthritis. A wound complication was defined as a hematoma, bulla, drainage or superficial infection. Stepwise multivariate logistic regression was used to identify which variables had a significant effect on the risk of wound complications. Variables considered were age, gender, body mass index, histories of previous knee surgery, comorbidities, duration of diabetes, the methods of diabetes treatment, complications of diabetes, preoperative HbA1c level, operation time, antibiotics-impregnated cement use, the amount of blood transfusion, and postoperative blood glucose level. The overall incidence of wound complications was 6.6% (n=11) including superficial infection in 1.8% (n=3), hematoma or bullae in 3.6% (n=6), and drainage in 1.8% (n=3). There were seven cases (4.2%) of deep infection. A multivariate logistic regression revealed that independent risk factors for the development of wound complications were preoperative HbA1C ≥ 8% (odds ratio 6.074, 95% confidence interval 1.119–32.971) and operation time (odds ratio 1.013, 95% confidence interval 1.000–1.026). Poorly controlled hyperglycemia before surgery may increase the incidence of wound complications among diabetic patients receiving total knee arthroplasties. The correlation of glycemic control and wound complications may assist in the preoperative evaluation and selection of time for surgery

Introduction: The aim of the study was to analyze the outcome of AO cannulated screws for fractures neck of femur in patients with Diabetes mellitus. Methods: of study: 62 patients aged 50 years or more (17 males & 45 females) who underwent AO screws for fracture neck of femur over 7 yrs (1999–2005) and followed-up for a minimum of 2 yrs formed the study population. A retrospective review of data from electronic patient record (EPR), clinical coding, clinic & GP letters was made. Age, residential placement, Garden’s classification of fracture, mode of injury, associated other co morbidities, pre-admission mobilisation status, allergies, addictions and anticoagulation status details were collected. An in depth study was conducted to look into delays for surgery, length of stay in hospital, complications and treatment of these complications. Reasons for re-admissions, re-operations and comorbidities developing as a result of these interventions were critically analysed. Post-op physiotherapy, proportion of patients sustaining contra-lateral fracture NOF & its management and mortality statistics were reviewed. Results: The mean age of patients was 67 yrs (range 52–96 yrs). 11 patients died in 2 years time. 41 patients were less than 75 years of age and 21 patients were more than 75 years of age. All the patients more than 75 years of age had undisplaced intracapsular fractures. 13 patients were type 1 and 49 patients were type 2 diabetic. Non-union & avascular necrosis occurred in 9 (17%) & 13 (26%) patients respectively. Revision surgery in the form of total hip replacement or hemiarthroplasty were performed in 21 (41%) cases. The incidence of avascular necrosis following osteosynthesis at 1 yr was 14%. Age, control of diabetes, post-operative complications, pre-fracture mobilization status and degree of impaction on AP & version on lateral radiographs were of statistical significance in predicting fracture healing and its associated complications. Complications like wound infection etc were more principally in patients who had poorly controlled diabetes. Conclusion: Patients with diabetes mellitus have metabolic bone disease due to vasculitis. This increases the risk of complications associated with fracture fixation such as non-union, cut-through and avascular necrosis (AVN). The complications and revision surgery rate was high in patients with displaced fractures and with poorly controlled diabetes. Comorbidities like diabetes & patient’s age were also strong predictors of healing in addition to fracture configuration. Looking at very high complication and reoperation rate, our recommendation in patients with diabetes is primary hemiarthroplasty irrespective of femoral head displacement, if there is age more than 75 years

The April 2015 Foot & Ankle Roundup³⁶⁰ looks at: Plantar pressures linked to radiographs; Strength training for ankle instability?; Is weight loss good for your feet?; Diabetes and foot surgery complications; Tantalum for failed ankle arthroplasty?; Steroids, costs and Morton’s neuroma; Ankle arthritis and subtalar joint

Total hip replacement causes a short-term increase in the risk of mortality. It is important to quantify this and to identify modifiable risk factors so that the risk of post-operative mortality can be minimised. We performed a systematic review and critical evaluation of the current literature on the topic. We identified 32 studies published over the last 10 years which provide either 30-day or 90-day mortality data. We estimate the pooled incidence of mortality during the first 30 and 90 days following hip replacement to be 0.30% (95% CI 0.22 to 0.38) and 0.65% (95% CI 0.50 to 0.81), respectively. We found strong evidence of a temporal trend towards reducing mortality rates despite increasingly co-morbid patients. The risk factors for early mortality most commonly identified are increasing age, male gender and co-morbid conditions, particularly cardiovascular disease. Cardiovascular complications appear to have overtaken fatal pulmonary emboli as the leading cause of death after hip replacement.

Cite this article: Bone Joint Res 2014;3:175–82

The February 2014 Hip & Pelvis Roundup³⁶⁰ looks at: length of stay; cementless metaphyseal fixation; mortality trends in over 400,000 total hip replacements; antibiotics in hip fracture surgery; blood supply to the femoral head after dislocation; resurfacing and THR in metal-on-metal replacement; diabetes and hip replacement; bone remodelling over two decades following hip replacement; and whether bisphosphonates affect acetabular fixation.

The February 2014 Research Roundup³⁶⁰ looks at: blood supply to the femoral head after dislocation; diabetes and hip replacement; bone remodelling over two decades following hip replacement; sham surgery as good as arthroscopic meniscectomy; distraction in knee osteoarthritis; whether joint replacement prevent cardiac events; tranexamic acid and knee replacement haemostasis; cartilage colonisation in bipolar ankle grafts; CTs and proof of fusion; atorvastatin for muscle re-innervation after sciatic nerve transection; microfracture and short-term pain in cuff repair; promising early results from L-PRF augmented cuff repairs; and fatty degeneration in a rodent model.