Aim. There is a constant increase of joint arthroplasties to improve the quality of life of an aging population. Prosthetic-joint infections are rare, with an incidence of 1–2%, but they represent serious complications in terms of morbidity and mortality. The mortality was known to be approaching 8% in the elderly. The aim of this retrospective study is to reassess the two-year mortality rate over the last ten years. Method. Patients having a prosthetic joint infection at Lausanne University Hospital (Switzerland) between 2006 and 2016 were included. The two-year mortality rate depending on sex, age, type of infection and type of surgical therapy was measured. Results. 444 patients (61% hips, 37% knees) were identified with a median age of 70 years. The two-year mortality rate was 5%. There was no difference between hip and knee prosthesis but the mortality was higher for men (6%) than women (4%). The rate has not changed over the last ten years. However, the mortality rate is more than doubling (12%) for patients over eighty years old. Furthermore, chronic prosthetic-joint infections seem to have a higher mortality rate (7%) than acute ones (4%). Finally, patients treated with a one-stage or two-stage exchange seem to have a lower mortality rate (<1%) than the ones treated with debridement and retention (11%). Conclusion. The mortality seems to be less than thought before and depends on sex, age, type of infection and type of surgical therapy

Aims. Traumatic central cord syndrome (CCS) typically follows a hyperextension injury and results in a motor impairment affecting the upper limbs more than the lower limbs, with occasional sensory impairment and urinary retention seen. Current evidence on mortality and long-term outcomes is limited. The primary aim of this study is to assess the five-year mortality of CCS, and to determine any difference in mortality between management groups or age. Patients and Methods. Patients ≥18 years with traumatic CCS between January 2012 and December 2017 in Wales were identified. Patient demographics and injury, management and outcome data was collected. Statistical analysis was performed to assess mortality and between group differences. Results. 65 patients were identified (66.2% male, mean age 63.9 years). At five-years follow-up, 32.3% (n=21) of CCS patients were dead. 6 (9.2%) patients had died within 31 days of their injury. 69.2% (n=45) of patients were managed conservatively and there was no significant difference (p=0.062) in age between conservatively and surgically managed patients. Kaplan-Meier analysis revealed no significant difference in mortality between patients managed conservatively compared to those managed surgically (log rank test, p=0.819). However, there was a significant difference (p=0.001) in mortality between the different age groups (<50 years vs 50–70 years vs >70 years). At five-years follow up, 55.6% of the patient group aged >70 years at time of injury were dead. Respiratory failure was the most common cause of death (n=9, 42.9%). Conclusion. Almost one third of patients with traumatic CCS in Wales were dead at five years following their injury. Management type did not significantly affect mortality, however age at time of injury did. Further work assessing the long-term functional outcomes of surviving patients is needed, to allow more reliable prognostic information and functional recovery predictions to be given

Abstract. Background. Elderly patients with degenerative lumbar disease are increasingly undergoing posterior lumbar decompression without instrumented stabilisation. There is a paucity of studies examining clinical outcomes, morbidity & mortality associated with this procedure in this population. Methods. A retrospective analysis of aged 80–100 years who underwent posterior lumbar decompression without instrumented stabilisation at University Hospitals of Derby &Burton between 2016–2020. Results. Total 167 eligible patients, 163 octogenarians & 4 nonagenarians. Mean age was 82.78 ± 3.07 years. Mean length of hospital stay 4.79 ± 10.92 days. 76% were pain free at 3months following decompression. The average Charleston co-morbidity index (CCI) was 4.87. No association found with CCI in predicting mortality (ODD ratio 0.916, CI95%). 17patients suffered complications; dural tear (0.017%), post-op paralysis (0.017%), SSI(0.01%), and 0.001% of hospital acquired pneumonia, delirium, TIA, urinary retention, ileus, anaemia. High BMI (35+) was associated with increased incidence of complication (CI 95%, p<0.002). There was significant social drift following discharge as 147 patients went home and 4 patients to rehabilitation facility (p<0.001FE test). The mean operative time was 91.408±41.17 mins and mean anaesthetic time was 36.8±16.06 mins. Prolonged operative time was not associated with increased mortality.2year revision decompression rate was 0.011%. Conclusion. Posterior lumbar decompression without instrumented stablisation in elderly is safe & associated with low mortality with 99.5%survival at 1 year. It significantly improves PROMs & has extremely low revision rate. Incidence of post-op complication is <0.05% and 54% of patients get discharged within 72hours of surgery. Careful selection & optimising patients with high BMI would reduced perioperative morbidity and mortality

Introduction. Neck of femur (NoF) fractures have an inherent 6.5% 30-day mortality as per National hip fracture database(2019). Several studies have demonstrated a higher mortality rate in covid positive NoFs but have been unable to demonstrate whether there are risk factors that contribute to the risk of mortality in this patient group or whether COVID is solely responsible for the higher mortality. Aims. To assess risk factors that are concurrently present in a fracture NoF cohort that may contribute to higher mortality in COVID positive patients. Methods. A cross sectional, retrospective study was performed for a period of 1 year starting from 1st March 2020. All surgically treated neck of femur fracture patients having an isolated intra/extracapsular fracture were included in the study. Data fields recorded- patient demographics, date and time of admission, ward discharge, surgery, mode of surgery (fixation/arthroplasty), prehospital AMTS score, residential status and mobility, ASA grade as per anaesthetist's records, date of death (if deceased), cause of death (as per death certificate/ postmortem / coroner's report). Analysis of mortality was carried out by creating a matched comparison group for each risk factor as well as some combinations. Results. 344 patients were surgically treated for a neck of femur fracture in our DGH during the period of 1st March 2020 to 28th February 2021. 46 patients did not receive a COVID swab (reasons unknown) and were excluded from the study. 35 patients had a COVID-19 RT PCR positive test during their hospital stay and 264 patients remained negative. There were 12 deaths in COVID positive patients (34%) and 53 deaths in COVID negative patients (20%) within the time frame of the study. For each risk factor matched group COVID was seen to confer higher mortality in general. There was no mortality in ASA 1 or 2 patients. Mortality rates in matched groups for age and ASA revealed 23.8% mortality in COVID positive as opposed to 17.3% in COVID negative for ASA 3 and 33.3% mortality in COVID positive vs. 28% in ASA 4. 11 out of the 12 COVID positive patients who died had an AMTS score >6. No correlation was seen between COVID positive deaths and preinjury residential status, type of fracture or surgery offered, or preinjury mobility. The average length of hospital stay was much higher for COVID positive patients (19.5days) as compared to 9.5 days for COVID negative patients. Conclusion. Matched group analysis show that there is a 37.5% increase in COVID positive neck of femur fracture mortality in ASA 3 patients, the same number falls to 17.8% for ASA 4 patients. These figures are much lower compared to other studies in the UK. There is a need to understand the real cause of death in this subset and to improve death certification so that we can differentiate between patients whose mortality is ‘due to’ or ‘With’ COVID

Background. Periprosthetic joint infection (PJI) following total knee arthroplasty (TKA) is a severe complication in terms of disability, morbidity, and cost. We performed a study to investigate whether early PJI (within 90 days of primary TKA) is associated with increased mortality. Secondary aims were to compare mortality rates over time and between surgical treatment methods. Methods. Patients with suspected PJI were identified by linkage of the Swedish Knee Arthroplasty Register (SKAR) and the Swedish Prescribed Drug Register (SPDR) in 2007–2008 and 2012–2013. Medical records of patients receiving more than 4 weeks of continuous antibiotic therapy were subsequently reviewed to verify the PJI diagnosis. Information on mortality was obtained through the SKAR which is updated daily from the tax agency and patients with PJI were compared to patients without PJI. Results. 466 patients were diagnosed with PJI within 90 days and compared to 40,362 patients without PJI. Mortality rates were significantly higher for PJI patients in both short- and long term: 2.6% vs. 0.8% at 1 year, 4.9% vs. 1.9% at 2 years, 15.7% vs. 7.1% at 5 years, and 38% vs. 21.4% at 10 years. The difference in mortality rate remained after adjusting for sex, age, diagnosis, and time period for surgery with Hazard Ratio 1.8 (95% CI:1.6–2.1). Mortality rates did not differ between time periods, and we found no correlation to surgical treatment. Conclusion. Patients with early PJI after primary TKA have an increased mortality rate compared to TKA patients without PJI. Improvements in surgical treatment strategy has not resulted in better survival. Long term difference in mortality rates indicates that PJI is not the sole reason for mortality suggesting a general frailty in PJI patients

Aim. To investigate the impact of waiting for surgical treatment for bone and joint infection (BJI) on patient self-reported quality of life (QoL). Method. Patients presenting to clinic between January 2019 and February 2020 completed the EuroQol EQ-5D-5L questionnaire. Patients were divided into three groups: surgery performed; on the waiting list for surgery; or decision for non-operative management. All patients were followed-up for 2 years. The EQ-index score was calculated and change from presentation to 1-year and 2-year follow-up was compared across the 3 groups. Mortality at final follow-up was measured in all groups. Results. 188 patients were included. Of these, 98 had an operation performed, 50 were on the waiting list for surgery but did not receive an operation and 40 were treated non-operatively. At presentation, all three groups had similar EQ-5D-5L index scores (surgery:0.412 SD0.351; waiting list:0.510 SD0.320; non-operative management: 0.467 SD0.354; p=0.269). There was a significant improvement in QoL in patients who underwent surgery when compared to their pre-operative state (mean increase of EQ-index score +0.241 in the first year (SD0.333, p<0.001) and +0.259 (SD0.294, p<0.001) in the second year. Patients on the waiting list for surgery had a small time-dependent decrease in EQ-index score at 1 year (−0.077, SD0.282, p=0.188) and 2 years (−0.140, SD0.359, p=0.401). Patients treated non-operatively had similar changes in EQ-index scores at 1 year (−0.052, SD0.309, p=0.561) and 2 years (−0.146, SD 0.234, p=0.221). Patients who had surgery had significantly better QoL at 2-years after treatment compared to other groups (mean EQ-index scores: surgery performed 0.671 vs. waiting list 0.431, p<0.001; surgery performed vs. non-operative management 0.348, p<0.001). Mortality in the operated group was 3.1%, which was similar to patients who were on the waiting list for surgery (6.5%, p=0.394) but lower than patients who were non-operatively managed (14.7%, p=0.014). Conclusions. The Covid-19 pandemic created long waiting times for some patients. Selecting patients with BJI who can safely wait for surgery is difficult. QoL for patients with BJI deteriorates over time if surgery is delayed or not performed. When patients decline surgery, they should be counselled that their QoL is likely to be impaired over time. The relationship between waiting time and mortality merits further study

Abstract. Introduction. The management of hip fractures has advanced on all aspects from prevention, specialised hip fracture units, early operative intervention and rehabilitation in line with increasing incidence in an aging population. Accurate data analysis on the incidence and trends of hip fractures is imperative to guide future management planning. Methods. A review of all articles published on mortality after hip fracture over a twenty year period (1999–2018) was undertaken to determine any changes that had occurred in the demographics and mortality over this period. This article complements and expands upon the findings of a previous article by the authors assessing a four decade period (1959 – 1998) and attempts to present trends and geographical variations over sixty years. Results. The mean age of patients sustaining hip fractures has increased from 73 years (1960s) to 81 years (2000s) to 82 years (2010s). Over the six decade period one-year mortality has reduced from 27% (1960s) to 20% (2010s). The proportion of female hip fractures has decreased from 84% (1960s) to 70% in 2010s. Intracapsular fractures have drecreased from 54% (1970s) to 49% (2000s) and 48% (2010s). Conclusion. Our study indicates that progress has been made with preventative planning, medical management, specialised orthogeriatric units and surgical expediency all playing a role in the improvements in mean age of hip fracture and reduction in mortality rates. While geographical variations do still exist there has been an increase in the study of hip fractures globally indicating increased attention and commitment to an

Direct oral anticoagulant (DOAC) use is becoming more widespread in the geriatric population. Depending on the type of DOAC, several days are required for its anticoagulant effects to resorb, which may lead to surgical delays. This can have an important impact on hip fracture patients who require surgery. The goal of the current study is to compare surgical delays, mortality and complications for hip fracture patients who were on a DOAC to those who were not. A retrospective cohort study was conducted at a university hospital in Sherbrooke. All hip fracture patients between 2012 and 2018 who were on a DOAC prior to their surgery were included. These patients were matched with similar patients who were not on an anticoagulant (non-DOAC) for age, sex, type of fracture and date of operation. Demographic and clinical data were collected for all patients. Surgical delay was defined as time of admission to time of surgery. Mortality and complications up to one year postoperative were also noted. Each cohort comprised of 74 patients. There were no statistically signification differences in Charleson Comorbidty Index and American Society of Anesthesiologists scores between cohorts. Surgical delay was significantly longer for DOAC patients (36.3±22.2 hours vs. 18.6±18.9 hours, p < 0 .001). Mortality (6.1%) and overall complication (33.8%) rates were similar between the two cohorts. However, there were more surgical reinterventions in DOAC patients than non-DOAC ones (16.2% vs. 0.0%, p < 0 .001). Among DOAC patients, mortality was greater for those operated after 48 hours (23.1% vs. 3.3%, p < 0 .05) and complications were more frequent for those operated after 24 hours (52.0% vs. 37.5%, p < 0 .05). Direct oral anticoagulant (DOAC) use in hip fracture patients is associated with longer surgical delays. Longer delays to surgery are associated with higher mortality and complication rates in hip fracture patients taking a DOAC. Hip fracture patients should have their surgery performed as soon as medically possible, regardless of anticoagulant use

Direct oral anticoagulant (DOAC) use is becoming more widespread in the geriatric population. Depending on the type of DOAC, several days are required for its anticoagulant effects to resorb, which may lead to surgical delays. This can have an important impact on hip fracture patients who require surgery. The goal of the current study is to compare surgical delays, mortality and complications for hip fracture patients who were on a DOAC to those who were not. A retrospective cohort study was conducted at a university hospital in Sherbrooke. All hip fracture patients between 2012 and 2018 who were on a DOAC prior to their surgery were included. These patients were matched with similar patients who were not on an anticoagulant (non-DOAC) for age, sex, type of fracture and date of operation. Demographic and clinical data were collected for all patients. Surgical delay was defined as time of admission to time of surgery. Mortality and complications up to one year postoperative were also noted. Each cohort comprised of 74 patients. There were no statistically signification differences in Charleson Comorbidty Index and American Society of Anesthesiologists scores between cohorts. Surgical delay was significantly longer for DOAC patients (36.3±22.2 hours vs. 18.6±18.9 hours, p < 0 .001). Mortality (6.1%) and overall complication (33.8%) rates were similar between the two cohorts. However, there were more surgical reinterventions in DOAC patients than non-DOAC ones (16.2% vs. 0.0%, p < 0 .001). Among DOAC patients, mortality was greater for those operated after 48 hours (23.1% vs. 3.3%, p < 0 .05) and complications were more frequent for those operated after 24 hours (52.0% vs. 37.5%, p < 0 .05). Direct oral anticoagulant (DOAC) use in hip fracture patients is associated with longer surgical delays. Longer delays to surgery are associated with higher mortality and complication rates in hip fracture patients taking a DOAC. Hip fracture patients should have their surgery performed as soon as medically possible, regardless of anticoagulant use

Aims. Now that we are in the deceleration phase of the COVID-19 pandemic, the focus has shifted to how to safely reinstate elective operating. Regional and speciality specific data is important to guide this decision-making process. This study aimed to review 30-day mortality for all patients undergoing orthopaedic surgery during the peak of the pandemic within our region. Methods. This multicentre study reviewed data on all patients undergoing trauma and orthopaedic surgery in a region from 18 March 2020 to 27 April 2020. Information was collated from regional databases. Patients were COVID-19-positive if they had positive laboratory testing and/or imaging consistent with the infection. 30-day mortality was assessed for all patients. Secondly, 30-day mortality in fracture neck of femur patients was compared to the same time period in 2019. Results. Overall, 496 operations were carried out in 484 patients. The overall 30-day mortality was 1.9%. Seven out of nine deceased patients underwent surgery for a fractured neck of femur. In all, 27 patients contracted COVID-19 in the peri-operative period; of these, four patients died within 30 days (14.8%). In addition, 21 of the 27 patients in this group had a fractured neck of femur, 22 were over the age of 70 years (81.5%). Patients with American Society of Anesthesiologists (ASA) grade > 3 and/or age > 75 years were at significantly higher risk of death if they contracted COVID-19 within the study period. Conclusion. Overall 30-day postoperative mortality in trauma and orthopaedic surgery patients remains low at 1.9%. There was no 30-day mortality in patients ASA 1 or 2. Patients with significant comorbidities, increasing age, and ASA 3 or above remain at the highest risk. For patients with COVID-19 infection, postoperative 30-day mortality was 14.8%. The reintroduction of elective services should consider individual patient risk profile (including for ASA grade). Effective postoperative strategies should also be employed to try and reduce postoperative exposure to the virus. Cite this article: Bone Joint Open 2020;1-7:392–397

Aim. Prosthetic joint infections (PJI) and fracture related infections (FRI) are the most challenging complications in orthopaedic surgery. An interdisciplinary approach is mandatory not only to correctly diagnose and treat major musculoskeletal infections but also to address the comorbidities and impairments these patients are not rarely suffering from. Since, little data exists on cardiac complications following PJI and FRI revision surgery, this study aimed to investigate the risk of perioperative myocardial injury (PMI) and mortality. Method. We prospectively included consecutive patients at high cardiovascular risk (defined as expected postoperative hospital stay of >24 hours PLUS age >45 years with pre-existing coronary, peripheral or cerebrovascular artery disease OR age >65 years) undergoing major orthopaedic surgery between 2014 and 2016. All patients received a systematic screening to reliably detect PMI, using serial measurements of high-sensitivity cardiac troponin T (hs-cTnT). All-cause mortality was assessed at 30 days and one year. Multivariable logistic regression models were applied to compare incidence of PMI and mortality between patients undergoing septic revision surgery (for PJI/FRI) and patients receiving aseptic major bone and joint surgery. Results. In total 911 consecutive patients, with an overall PMI rate of 15.4% (n=140) were included. The PMI incidence in patients undergoing septic revision surgery was significantly higher compared to aseptic orthopaedic surgeries (29.2% vs 14.3%, p=0.001), also after multivariable adjustment (odds ratio 2.1, p=0.02). Mortality was higher at one year (16.9% vs. 8.3%, p=0.037) and numerically at 30 days (6.2% vs. 2.4%, p=0.085) in patients undergoing septic revision surgery. Virulence of the disease-causing pathogen showed no significant relationship with PMI incidence or mortality. Conclusions. Patients undergoing revision surgery for PJI or FRI were at a distinct higher risk of PMI and death compared to matched non-septic patients. In major bone and joint infections screening for PMI and treatment in specialized multidisciplinary units should be considered

Abstract. Introduction. There is paucity of evidence in predicting outcomes following cervical decompression in patients in octogenerians with cervical myelopathy. Our aim is to analyse the predictive value of Charlson comorbidity index (CCI) on clinical outcomes in this group. Methods. All patients age >80 years who underwent cervical decompression+/−stabilisation between January 2006-December 2021 at University Hospitals of Derby & Burton were included. Logistic regression analysis was performed using JASP. Results. Total 72 patients (n=32 male, n=28 female). Mean age 83.44 ± 3.21 years. 67 patients underwent posterior decompression+ stabilisation & 5 patients had posterior decompression alone. Mean CCI was 5; graded moderate in 32 (44%, CCI=<4) and severe in 40 (55.5%, CCI>4). Mean age and preoperative Nurick grade was similar between moderate and severe groups. Postoperative Nurick grade improved equally in both groups by 0.67 and 0.68 respectively (p=0.403). Mean LOS 16±16.12 days. 5 complications in the moderate group (21.8%) and 8 complications in severe group (21.6%); wound infection (n=7), other infection (n=2), electrolyte derangement (n=2), AKI (n=1), blood transfusion (n=1) and early death (n=3) (p=0.752). 1 early postoperative death <30 days occurred in the moderate group (4.3%) whereas 2 occurred in the severe group (5.3%) (p=0.984). No patients with moderate CCI required nursing home discharge whereas 7.9% of severe patients required this. Conclusion. Both groups benefitted from neurological improvement postoperatively, low 1 year mortality. No difference in hospital stay, complication rate and early mortality between both groups. More patients with severe CCI require nursing care after discharge than those with moderate CCI

To analyse the causes and factors associated with mortality in patients admitted to ASCI unit in a low- or middle-income country. The study was performed at a Tertiary Hospital at Groote Schuur Hospital, Cape Town South Africa. Data between 1996 –2022 were retrospectively collected from hospital records of patients admitted to the ASCI Unit. There was approximately 3223 admissions for the study period. 682 patients were confirmed dead 87% were male and 64% were unemployed. The mean age was 46 years (ranging from 14 – 87 years). A 1/3 of injuries were caused by a MVA, a ¼ by a fall (low energy and from a height), and 1/5 by a gunshot wound. Average length of stay was 47 days (SD = 52 days), ranging from as short as 1 day to 512 days for one patient. Majority (65%) were admitted for more than a week but less than 2 months 32% were ventilated, and 17% with a CPAP facemask. 10% of patients had a pre-existing ulcer prior to admission. 65% of patients had surgery via the posterior approach, 33% via the anterior approach. On average patients died within 5 years of being admitted to hospital, ranging from dying in the same year as the injury to 20 years later. 73% of the deaths were classified as natural deaths and 20% as unnatural. There is a high mortality in patients with acute spinal cord injury, causes are multifactorial, and in depth critical analyses is required to improve clinical outcomes and rationalise resource allocation

Sarcopenia has been observed to be a predictor of mortality in international studies of patients with metastatic disease of the spine. This study aimed to validate sarcopenia as a prognostic tool in a New Zealand setting. A secondary aim of this study was to assess the intra-observer reliability of measurements of psoas and vertebral body cross sectional areas on computed tomography imaging. A cohort of patients who had presented to Waikato Hospital with secondary neoplasia in the spinal column from 2014 to 2018 was selected. Cross sectional psoas and vertebral body areas were measured at the mid-pedicle L3 level, followed by calculation of the psoas to vertebral body cross sectional area ratio. Psoas to vertebral body cross sectional area ratio was compared with survivorship. The strength of the correlation between sarcopenia and survivorship was compared with the correlation between serum albumin and survivorship, as well as the correlation between the Metastatic Spine Risk Index (MSRI) and survivorship. A total of 110 patients who received operative (34) and non-operative (76) were included. The results demonstrate that psoas to vertebral body cross sectional area ratio is not statistically significantly correlated with survivorship (p=0.53). Serum albumin is significantly correlated with survivorship (p<0.0001), as was the MSRI. There is good intra-observer and inter-observer reliability for measurements of psoas to vertebral body cross sectional area. This study failed to demonstrate the utility for the psoas to vertebral body cross sectional area ratio that other studies have demonstrated in estimating survivorship. Serum albumin levels remain a useful prognostic indicator in patients with secondary tumours in the vertebral column

Abstract. Introduction. Minimising postoperative complications and mortality in COVID-19 patients who were undergoing trauma and orthopaedic surgeries is an international priority. Aim was to develop a predictive nomogram for 30-day morbidity/mortality of COVID-19 infection in patients who underwent orthopaedic and trauma surgery during the coronavirus pandemic in the UK in 2020 compared to a similar period in 2019. Secondary objective was to compare between patients with positive PCR test and those with negative test. Methods. Retrospective multi-center study including 50 hospitals. Patients with suspicion of SARS-CoV-2 infection who had underwent orthopaedic or trauma surgery for any indication during the 2020 pandemic were enrolled in the study (2525 patients). We analysed cases performed on orthopaedic and trauma operative lists in 2019 for comparison (4417). Multivariable Logistic Regression analysis was performed to assess the possible predictors of a fatal outcome. A nomogram was developed with the possible predictors and total point were calculated. Results. Of the 2525 patients admitted for suspicion of COVID-19, 658 patients had negative preoperative test, 151 with positive test and 1716 with unknown preoperative COVID-19 status. Preoperative COVID-19 status, sex, ASA grade, urgency and indication of surgery, use of torniquet, grade of operating surgeon and some comorbidities were independent risk factors associated with 30-day complications/mortality. The 2020 nomogram model exhibited moderate prediction ability. In contrast, the prediction ability of total points of 2019 nomogram model was excellent. Conclusions. Nomograms can be used by orthopaedic and trauma surgeons as a practical and effective tool in postoperative complications and mortality risk estimation

En bloc resection for primary bone tumours and isolated metastasis are complex surgeries associated with a high rate of adverse events (AEs). The primary objective of this study was to explore the relationship between frailty/sarcopenia and major perioperative AEs following en bloc resection for primary bone tumours or isolated metastases of the spine. Secondary objectives were to report the prevalence and distribution of frailty and sarcopenia, and determine the relationship between these factors and length of stay (LOS), unplanned reoperation, and 1-year postoperative mortality in this population. This is a retrospective study of prospectively collected data from a single quaternary care referral center consisting of patients undergoing an elective en bloc resection for a primary bone tumour or an isolated spinal metastasis between January 1st, 2009 and February 28th, 2020. Frailty was calculated with the modified frailty index (mFI) and spine tumour frailty index (STFI). Sarcopenia, determined by the total psoas area (TPA) vertebral body (VB) ratio (TPA/VB), was measured at L3 and L4. Regression analysis produced ORs, IRRs, and HRs that quantified the association between frailty/sarcopenia and major perioperative AEs, LOS, unplanned reoperation and 1-year postoperative mortality. One hundred twelve patients met the inclusion criteria. Using the mFI, five patients (5%) were frail (mFI ³ 0.21), while the STFI identified 21 patients (19%) as frail (STFI ³ 2). The mean CT ratios were 1.45 (SD 0.05) and 1.81 (SD 0.06) at L3 and L4 respectively. Unadjusted analysis demonstrated that sarcopenia and frailty were not significant predictors of major perioperative AEs, LOS or unplanned reoperation. Sarcopenia defined by the CT L3 TPA/VB and CT L4 TPA/VB ratios significantly predicted 1-year mortality (HR of 0.32 per one unit increase, 95% CI 0.11-0.93, p=0.04 vs. HR of 0.28 per one unit increase, 95% CI 0.11-0.69, p=0.01) following unadjusted analysis. Frailty defined by an STFI score ≥ 2 predicted 1-year postoperative mortality (OR of 2.10, 95% CI 1.02-4.30, p=0.04). The mFI was not predictive of any clinical outcome in patients undergoing en bloc resection for primary bone tumours or isolated metastases of the spine. Sarcopenia defined by the CT L3 TPA/VB and L4 TPA/VB and frailty assessed with the STFI predicted 1-year postoperative mortality on univariate analysis but not major perioperative AEs, LOS or reoperation. Further investigation with a larger cohort is needed to identify the optimal measure for assessing frailty and sarcopenia in this spine population

This study was designed to compare atypical hip fractures with a matched cohort of standard hip fractures to evaluate the difference in outcomes. Patients from the American College of Surgeons National Surgical Quality Improvement Program's (NSQIP) targeted hip fracture data file (containing a more comprehensive set of variables collected on 9,390 specially targeted hip fracture patients, including the differentiation of atypical from standard hip fractures) were merged with the standard 2016 NSQIP data file. Atypical hip fracture patients aged 18 years and older in 2016 were identified via the targeted hip fracture data file and matched to two standard hip fracture controls by age, sex, and fracture location. Patient demographics, length of hospital stay, 30-day mortality, major and minor complications, and other hip-specific variables were identified from the database. Binary outcomes were compared using the McNemar's test for paired groups, and continuous outcomes were compared using a paired t-test. Ninety-five atypical hip fractures were identified, and compared to 190 age, sex, and fracture location matched standard hip fracture controls. There was no statistical difference in body mass index (BMI), race, ASA score, smoking status, timing of fixation, or functional status between the two groups (P>0.05). Thirty-day mortality was significantly higher in the atypical hip fracture group (atypical 7.36%, standard 2.11% p. This is the first study, to our knowledge, that demonstrates an increase in the rate of mortality in atypical hip fractures. Comparing atypical hip fractures with a matched cohort of standard hip fractures revealed a significantly greater 30-day mortality rate with an odds ratio of 3.62 in atypical hip fractures (95% CI 1.03–12.68). Prospective, clinical studies are recommended to further investigate these findings

Aims. The primary aim of this study was to assess the independent association of the coronavirus disease 2019 (COVID-19) on postoperative mortality for patients undergoing orthopaedic and trauma surgery. The secondary aim was to identify factors that were associated with developing COVID-19 during the postoperative period. Methods. A multicentre retrospective study was conducted of all patients presenting to nine centres over a 50-day period during the COVID-19 pandemic (1 March 2020 to 19 April 2020) with a minimum of 50 days follow-up. Patient demographics, American Society of Anesthesiologists (ASA) grade, priority (urgent or elective), procedure type, COVID-19 status, and postoperative mortality were recorded. Results. During the study period, 1,659 procedures were performed in 1,569 patients. There were 68 (4.3%) patients who were diagnosed with COVID-19. There were 85 (5.4%) deaths postoperatively. Patients who had COVID-19 had a significantly lower survival rate when compared with those without a proven SARS-CoV-2 infection (67.6% vs 95.8%, p < 0.001). When adjusting for confounding variables (older age (p < 0.001), female sex (p = 0.004), hip fracture (p = 0.003), and increasing ASA grade (p < 0.001)) a diagnosis of COVID-19 was associated with an increased mortality risk (hazard ratio 1.89, 95% confidence interval (CI) 1.14 to 3.12; p = 0.014). A total of 62 patients developed COVID-19 postoperatively, of which two were in the elective and 60 were in the urgent group. Patients aged > 77 years (odds ratio (OR) 3.16; p = 0.001), with increasing ASA grade (OR 2.74; p < 0.001), sustaining a hip (OR 4.56; p = 0.008) or periprosthetic fracture (OR 14.70; p < 0.001) were more likely to develop COVID-19 postoperatively. Conclusion. Perioperative COVID-19 nearly doubled the background postoperative mortality risk following surgery. Patients at risk of developing COVID-19 postoperatively (patients > 77 years, increasing morbidity, sustaining a hip or periprosthetic fracture) may benefit from perioperative shielding. Cite this article: Bone Joint J 2020;102-B(12):1774–1781

Aim. Staphylococcus aureus bacteremia (SAB) is associated with significant morbidity and mortality, 20–30 % risk of infection in patient with implant related infection (IRI) .18F-FDG PET/CT is helpful in the management of SAB, leading to detection of more metastatic foci and treatment modification and finally decrease relapses and mortality rate. Our objective was to analyze mortality in high risk SAB patients undergoing 18F-FDG PET/CT and to see whether it's use in patients with IRI reduced their mortality. Method. We performed a retrospective study at a university hospital in Belgium. All cases of high risk adult SAB between January 2014 and June 2017 were reviewed. We collected the clinical characteristics including presence of metastatic foci on 18F-FDG PET/ CT, mortality at 1 year. Results. A total of 102 patients were included. Twenty-one patient with IRI were identified (20.6%). In 94.1 % (N=96) SAB were due to methicillin-sensitive staphylococcus aureus (MSSA). 18F-FDG PET/ CT was performed in 47% (N =48) of patients and a metastatic foci was identified in 45.8% of cases (N=22/48). The detection of metastatic foci lead to surgical intervention in a site other than the site of IRI in 38% versus 14% (P < 0.001) in patients undergoing or not 18F-FDG PET/CT respectively. The overall mortality rate was 31.3 % (32/102). The mortality rate was 16.6% (8 /48) and 41.3 % (24/54) in patients undergoing or not 18F-FDG PET/ CT respectively (P=0.03). For IRI, the overall mortality was 9.3 % versus 15.6% in patients undergoing or not 18F-FDG PET/ CT respectively (P<0.001). There was a significant difference in mortality rate at 30 (P=0.001), 90 days (P–0.01) and one year (P–0.004) between patients undergoing or not 18F-FDG PET/ CT respectively. In bivariate analysis, the overall, 30, 90 days and one year mortality rate was significantly reduced among patient with kidney failure (P< 0.001), diabetic foot infection (P=0.006), age >70 years (P=0.007) and prosthetic joint or plate infection (P< 0.001) in whom the 18F-FDG PET/ CT was performed. Conclusions. Mortality rate was reduced in high risk SAB patients undergoing 18F-FDG PET/ CT. The use of 18F-FDG PET/CT reduced mortality in patients with PJI by detecting more metastatic site leading to more aggressive treatment

Aim. Acute hematogenous periprosthetic joint infection (AHI) is a diagnosis on the rise. The management is challenging and the optimum treatment is not clearly defined. The purpose of this study was to evaluate the characteristics of AHI, and to study risk factors affecting treatment outcome. Methods. We retrospectively analysed 44 consecutive episodes with AHI in a total hip or knee arthroplasty beween 2013 and 2020 at a single center. AHI was defined as abrupt symptoms of infection ≥ 3 months after implantation in an otherwise well functioning arthroplasty. We used the Delphi criteria to define treatment failure with a minimum of 1-year follow-up. Results. AIH was most often caused by Staphylococcus aureus (36%) and streptococcal species (32%), but a broad spectrum of microbes were identified. The majority of patients (25/44) were treated with debridement and retention of the implant (DAIR), with a success rate of 40%, significantly lower than in patients treated with removal of the implant (94%, p=0.001). Staph aureus infections (p=0.004), knee arthroplasties (p=0.03), and implant-age < 2 years (p=0.034) were associated with treatment failure. The 2-year mortality rate was 19%. Conclusions. The main findings in this study were that outcome following DAIR in AHIs is poor, that the majority of infections were caused by virulent microbes, and we found a high mortality rate. Removal of the implant should more often be considered