Cite this article: Bone Jt Open 2024;5(12):1120–1122.

Aims. Arthroplasty has been shown to generate the most waste among all orthopaedic subspecialties, and it is estimated that hip and knee arthroplasty generate in excess of three million kg of waste annually in the UK. Infectious waste generates up to ten times more CO2 compared with recycled waste, and previous studies have shown that over 90% of waste in the infectious stream is misallocated. We assessed the effect of real-time waste segregation by an unscrubbed team member on waste generation in knee and hip arthroplasty cases, and compared this with a simple educational intervention during the ‘team brief’ at the start of the operating list across two sites. Methods. Waste was categorized into five categories: infectious, general, recycling, sharps, and linens. Each category was weighed at the end of each case using a digital weighing scale. At Site A (a tertiary orthopaedic hospital), pre-intervention data were collected for 16 total knee arthroplasy (TKA) and 15 total hip arthroplasty (THA) cases. Subsequently, for ten TKA and ten THA cases, an unscrubbed team member actively segregated waste in real-time into the correct streams. At Site B (a district general hospital), both pre- and post-intervention groups included ten TKA and ten THA cases. The intervention included reminding staff during the ‘team brief’ to segregate waste correctly. Results. Active real-time waste segregation reduced infectious waste by a mean of 2.51 kg (95% CI 1.492 to 3.542) in TKA, and 1.83 kg in THA cases (p = 0.004). Educational intervention reduced infectious waste by a mean of 3.52 kg in TKA and 2.09 kg in THA cases (p = 0.026). Total waste was significantly reduced in both groups post-intervention for TKA cases. Conclusion. Simple educational measures alone can significantly reduce the amount of infectious waste. Extrapolated nationally, our results would yield a reduction of approximately 315,004 kg to 594,577 kg of CO2 annually, which equates to 70 to 132 gasoline-powered passenger vehicles driven for a year. Cite this article: Bone Jt Open 2024;5(12):1119–1124

Objectives. Our aim to study the incidence, demographics, inpatient stay, use of imaging and outcomes of patients who have non-operatively managed NOF fractures. Study Design & Methods. The data was collected retrospectively for the last 14 years (Jan 2009- Jan 2023) of all non-operatively managed NOF fractures at a level 2 trauma centre. The data was collected from the trauma board, electronic patient records, radiographs, and National Hip Fracture Database (NHFD). The data collected as demographic details, fracture classification, any reasons for non-operative management, mortality and further surgical management was done. Patients who died or transferred to other sites for specialist surgery were excluded. Results. Our results showed that 1.7% (62/4132) of NOF fractures were managed non-operatively at our institution. The reasons for non-operative management were as follows, medically unwell 45% (n = 28) in whom operative risk was thought to outweigh benefit and risk of death was high within the 48 - 72 hrs of admission. The second group patients, minimal or no pain and old fractures with comfortable mobilisation 55% (n = 34). Out of 34 /62 patients who were mobilised, 14% (5/34) of this patient subgroup subsequently required surgical intervention for failed non-operative management. In the medically unwell group (28/62) the 30-day mortality was 32% (12/28) with a 1-year mortality rate of 42% (17/28). The patients who were mobilised (34/62) the 30-day mortality was 6% (4/34) with a 1-year mortality rate of 20% (5/34). The combined average 1 year mortality for this cohort was 35% (22/62). Conclusions. Our study showed higher mortality rate for medically unwell group 42%. The patients whose fractures are stable enough to allow them to mobilise comfortably showed 20% 1-year mortality rate and 14% surgical intervention needed in 14 % (5/34) patients. We note that an analysis is necessary to assess the functional outcomes of this subgroup, as well as the potential cost implications. The combined average 1 year mortality for this cohort was 35% (22/62) which was due to the high-risk factors in medically unwell group

Objectives. Acetabular fractures with quadrilateral plate involvement have been shown to have a high rate of complications. Anatomic suprapectineal plating systems have been developed to manage these injuries with good short-term outcomes, however long-term maintenance of anatomical reduction and functional outcomes is yet to be established. Efficacy of maintenance of reduction and functional outcomes at a minimum of 5-years follow-up is the aim of this study. Design and Methods. A retrospective cohort study examining patients aged over 16 years following fixation of acetabular fractures with quadrilateral plate involvement at a trauma centre in the United Kingdom. All patients had acetabular fracture fixation with an anatomically designed suprapectineal plate. Patients were admitted from March 2014 to January 2017. Primary outcomes included objective radiological outcomes such as reduction quality, maintenance of reduction, metalwork failure, complications (such as reoperation, neurological deficit and mortality) and subjective patient-related outcome measures (PROMs) using the Oxford Hip Score and EuroQol EQ5D Score at a minimum of 5-years post-operatively. Results. 16 patients met our eligibility criteria in this cohort. Post-operative mean Oxford Hip Score (OHS) at a minimum of 5-years was 40.5 (SD 11.9) with a median score of 45. Post-operative mean EuroQol EQ-5D scores at a minimum of 5-years were 0.83 (SD 0.25). Comparison of OHS and EQ5D at 1-year and 5-years showed no significant difference (OHS p = 0.27 / EQ5D p = 0.128). Radiographic outcomes were assessed with AP and Judet plain radiographs at a minimum of 5-years follow-up. Rate of conversion to total hip replacement was 6.25%. 56.3% showed some evidence of dome comminution with 18.8% demonstrating dome impaction. 93.7% showed evidence of quadrilateral plate involvement. 12.5% showed evidence of femoral head injury. Conclusion. Maintenance of reduction and functional and patient reported outcomes using anatomically contoured suprapectineal plates do not change significantly between 1 year and 5 years follow-up

Objectives. As per NICE guidance, one of the cornerstones of management of AKI is risk assessment. Aim of the audit is to identify the potential risk factors for postoperative AKI in hip fracture patients. Design and Methods. Using local NOF registration data, Patient details were selected using inclusion and exclusion criteria. Electronic records of patients were assessed retrospectively including blood results, radiological investigations, clinical documentation and drug chart. Inclusion Criteria: All patients > 50 years old with NOF fractures underwent operative management from January 2022 to June 2022 Exclusion Criteria: 1- Pathological fractures. 2- Non-operative management. 3- Died directly postoperative. Results. 250 patients underwent hip fracture surgery at our hospital in 6 months (January 2022-June 2022) (Cemented Procedures were 133 (53 %) while Fixation procedures were 117 (47%)). Female patients were 174 (70%), and male were 76 patients. Average age was 83.4 years and number of operations done over Weekend (Friday-Sunday) = 123 (49%). The incidence of Postoperative AKI was 56 (22.4%). Forty-five from fifty-six cases were stage 1 (80.4%) while 7 cases (12.5%) were stage 2. The studied risk factors for Postoperative AKI were: cemented procedures (61% of postoperative AKI incidence), female Gender (66%), time from admission to operation (>24 hours =33 %), day of operation (operations done Friday/Saturday/Sunday = 55%) and Postoperative antibiotics (71%). Conclusion. We need strategies to reduce incidence of postoperative AKI like: AKI alert on laboratory results, IV fluid prescription preoperative since arrival of patients to ED, avoid/stop nephrotoxic medications on admission, regular review of postoperative U&Es and fluid balance especially in high-risk patients, increase nursing staff and junior doctors on wards over weekends and we need to review our policy of giving postoperative IV antibiotics

Aims

This meta-analysis and systematic review aimed to comprehensively investigate the effects of vitamin K supplementation on bone mineral density (BMD) at various sites and bone metabolism in middle-aged and older adults.

Aims

Functional alignment (FA) in total knee arthroplasty (TKA) aims to achieve balanced gaps by adjusting implant positioning while minimizing changes to constitutional joint line obliquity (JLO). Although FA uses kinematic alignment (KA) as a starting point, the final implant positions can vary significantly between these two approaches. This study used the Coronal Plane Alignment of the Knee (CPAK) classification to compare differences between KA and final FA positions.

Aims. Better prediction of outcome after total hip arthroplasty (THA) is warranted. Systemic inflammation and central neuroinflammation are possibly involved in progression of osteoarthritis and pain. We explored whether inflammatory biomarkers in blood and cerebrospinal fluid (CSF) were associated with clinical outcome, and baseline pain or disability, 12 months after THA. Methods. A total of 50 patients from the Danish Pain Research Biobank (DANPAIN-Biobank) between January and June 2018 were included. Postoperative outcome was assessed as change in Oxford Hip Score (OHS) from baseline to 12 months after THA, pain was assessed on a numerical rating scale, and disability using the Pain Disability Index. Multiple regression models for each clinical outcome were included for biomarkers in blood and CSF, respectively, including age, sex, BMI, and Kellgren-Lawrence score. Results. Change in OHS was associated with blood concentrations of tumour necrosis factor (TNF), interleukin-8 (IL-8), interleukin-6 receptor (IL-6R), glycoprotein 130 (gp130), and IL-1β (R. 2. = 0.28, p = 0.006), but not with CSF biomarkers. Baseline pain was associated with blood concentrations of lymphotoxin alpha (LTα), TNFR1, TNFR2, and IL-6R (R. 2. = 0.37, p < 0.001) and CSF concentrations of TNFR1, TNFR2, IL-6, IL-6R, and IL-1Ra (R. 2. = 0.40, p = 0.001). Baseline disability was associated with blood concentrations of TNF, LTα, IL-8, IL-6, and IL-1α (R. 2. = 0.53, p < 0.001) and CSF concentrations of gp130, TNF, and IL-1β (R. 2. = 0.26, p = 0.002). Thus, preoperative systemic low-grade inflammation predicted 12-month postoperative outcome after THA, and was associated with preoperative pain and disability. Conclusion. This study highlights the importance of systemic inflammation in osteoarthritis, and presents a possible path for better patient selection for THA in the future. Preoperative central neuroinflammation was associated with preoperative pain and disability, but not change in OHS after THA. Cite this article: Bone Joint Res 2024;13(12):741–749

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Systematic reviews of randomized controlled trials (RCTs) are the highest level of evidence used to inform patient care. However, it has been suggested that the quality of randomization in RCTs in orthopaedic surgery may be low. This study aims to describe the quality of randomization in trials included in systematic reviews in orthopaedic surgery.

Aims

Extracellular matrix (ECM) is a critical determinant of tissue mechanobiology, yet remains poorly characterized in joint tissues beyond cartilage in osteoarthritis (OA). This review aimed to define the composition and architecture of non-cartilage soft joint tissue structural ECM in human OA, and to compare the changes observed in humans with those seen in animal models of the disease.

Aims

Lower limb reconstruction (LLR) has a profound impact on patients, affecting multiple areas of their lives. Many patient-reported outcome measures (PROMs) are employed to assess these impacts; however, there are concerns that they do not adequately capture all outcomes important to patients, and may lack content validity in this context. This review explored whether PROMs used with adults requiring, undergoing, or after undergoing LLR exhibited content validity and adequately captured outcomes considered relevant and important to patients.

The December 2024 Research Roundup. 360. looks at: Skeletal muscle composition, power, and mitochondrial energetics in older men and women with knee osteoarthritis; Machine-learning models to predict osteonecrosis in patients with femoral neck fractures undergoing internal fixation; Aetiology of patient dissatisfaction following primary total knee arthroplasty in the era of robotic-assisted technology; Efficacy and safety of commonly used thromboprophylaxis agents following hip and knee arthroplasty; The COVID-19 effect continues; Nickel allergy in knee arthroplasty: does self-reported sensitivity affect outcomes?; Tranexamic acid use and joint infection risk in total hip and knee arthroplasty

The December 2024 Arthroplasty Roundup. 360. looks at: Aspirin for hip and knee arthroplasty?; VTE prophylaxis; VTE prophylaxis part II

Aims. This study aimed to determine clinical outcomes; relationships between postoperative anterior, lateral, and posterior acetabular coverage and joint survival; and prognostic factors for joint survival after transposition osteotomy of the acetabulum (TOA). Methods. Data from 616 patients (800 hips) with hip dysplasia who underwent TOA between November 1998 and December 2019 were reviewed. The median follow-up period was 8.9 years (IQR 5 to 14). A medical notes review was conducted to collect demographic data, complications, and modified Harris Hip Score (mHHS). Radiological indicators of acetabular coverage included lateral centre-edge angle (LCEA), anterior wall index (AWI), and posterior wall index (PWI). The cumulative probability of TOA failure (progression to Tönnis grade 3 or conversion to total hip arthroplasty) was estimated using the Kaplan-Meier product-limited method. A multivariate Cox proportional hazards model was used to identify predictors for failure. Results. Median mHHS improved from 68 preoperatively to 96 at the latest follow-up (p < 0.001). The overall joint survival rate was 97% at ten years and 70% at 20 years. For the postoperative LCEA subgroups, survival in the deficient group was lower than that in the excessive (p = 0.006) and normal (p = 0.007) groups. For the postoperative AWI subgroups, survival in the deficient group was lower than that in the excessive (p = 0.015) and normal (p < 0.001) groups. Multivariate analysis identified age (p = 0.010), Tönnis grade 2 (p < 0.001), roundness index (p = 0.003), fair joint congruity (p = 0.004), and postoperative AWI (p = 0.002) as independent risk factors. Conclusion. Deficient postoperative AWI adversely affected joint survival after TOA, underscoring the importance of sufficient anterior acetabular coverage, along with precise surgical indications, to ensure successful hip joint preservation in the treatment of hip dysplasia. Cite this article: Bone Joint J 2024;106-B(12):1399–1407

Aims. Cutibacterium acnes (C. acnes; previously known as Propionibacterium acnes or P. acnes) periprosthetic hip and knee infections are under-reported. While culture contamination with C. acnes occurs, true infections are important to recognize and treat. We sought to describe the demographics and treatment outcomes of patients with C. acnes periprosthetic joint infections (PJIs) of the hip and knee. Methods. Patients with C. acnes PJI between January 2005 and December 2018 were retrospectively reviewed utilizing the institutional total joint registry. Patients with monomicrobial PJI and two or more positive cultures were considered to have true C. acnes PJI. Patients with polymicrobial infection or with only one positive culture were excluded. This resulted in 35 PJIs (21 hips and 14 knees); the patients’ mean age was 63 years (35 to 84) and 15 (43%) were female. Mean follow-up was five years (1 to 14). Results. The median time to positive culture was five days (IQR 5 to 6) and median synovial fluid cell count was 22,583 cells (IQR 15,200 to 53,231). The median ESR was 25 mm/hr (IQR 7 to 37), and CRP was 15 mg/l (IQR 3 to 29). Of the 35 PJIs, 18 (51%) were treated with chronic antibiotic suppression without surgical intervention, and the remainder were treated with two-stage exchange arthroplasty. The two-year survival free of any revision was 94%. Four patients failed treatment due to symptomatic infection, with three treated with two-stage exchange and one treated with irrigation and debridement with modular component exchange for a survival rate of 89% and 83% at two and five years, respectively. Conclusion. Laboratory evidence of C. acnes PJI in this cohort was typical compared to more conventional organisms. Cultures grew more quickly than previously thought in patients with C. acnes PJI. Treatment with two-stage exchange or chronic antibiotic suppression alone both had few treatment failures at mid-term follow-up. Cite this article: Bone Joint J 2024;106-B(12):1426–1430

In the UK, multidisciplinary teamwork for patients with hip fracture has been shown to reduce mortality and improves health-related quality of life for patients, while also reducing hospital bed days and associated healthcare costs. However, despite rapidly increasing numbers of fragility fractures, multidisciplinary shared care is rare in low- and middle-income countries around the world. The HIPCARE trial will test the introduction of multidisciplinary care pathways in five low- and middle-income countries in South and Southeast Asia, with the aim to improve patients’ quality of life and reduce healthcare costs. Cite this article: Bone Joint J 2024;106-B(12):1369–1371

The December 2024 Trauma Roundup³⁶⁰ looks at: Percutaneous lumbopelvic fixation is effective in the management of unstable transverse sacral fractures; A systematic review on autologous matrix-induced chondrogenesis (AMIC) for chondral knee defects; Stable clinical and radiological outcomes at medium and over five-year follow-up of calcaneus fracture open reduction internal fixation using a sinus tarsi approach; Right or left? It might make a difference; Suprapatellar versus infrapatellar tibial nailing – is there a difference in anterior knee pain and function?; Can patients safely weightbear following ankle fracture fixation?; Anterior-to-posterior or a plate fixation for posterior malleous fractures?; Audio distraction for traction pin insertion: a prospective randomized controlled study; Is intramedullary nailing of femoral diaphyseal fractures in the lateral decubitus position as safe and effective as on a traction table?

Periprosthetic joint infection (PJI) represents a complex challenge in orthopaedic surgery associated with substantial morbidity and healthcare expenditures. The debridement, antibiotics, and implant retention (DAIR) protocol is a viable treatment, offering several advantages over exchange arthroplasty. With the evolution of treatment strategies, considerable efforts have been directed towards enhancing the efficacy of DAIR, including the development of a phased debridement protocol for acute PJI management. This article provides an in-depth analysis of DAIR, presenting the outcomes of single-stage, two-stage, and repeated DAIR procedures. It delves into the challenges faced, including patient heterogeneity, pathogen identification, variability in surgical techniques, and antibiotics selection. Moreover, critical factors that influence the decision-making process between single- and two-stage DAIR protocols are addressed, including team composition, timing of the intervention, antibiotic regimens, and both anatomical and implant-related considerations. By providing a comprehensive overview of DAIR protocols and their clinical implications, this annotation aims to elucidate the advancements, challenges, and potential future directions in the application of DAIR for PJI management. It is intended to equip clinicians with the insights required to effectively navigate the complexities of implementing DAIR strategies, thereby facilitating informed decision-making for optimizing patient outcomes.

Cite this article: Bone Joint J 2024;106-B(12):1377–1384.