The aim of this study was to compare the operating time, length of stay (LOS), adverse events and rate of re-admission for elderly patients with a fracture of the hip treated using either general or spinal anaesthesia. Patients aged ≥ 70 years who underwent surgery for a fracture of the hip between 2010 and 2012 were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Of the 9842 patients who met the inclusion criteria, 7253 (73.7%) were treated with general anaesthesia and 2589 (26.3%) with spinal anaesthesia. On propensity-adjusted multivariate analysis, general anaesthesia was associated with slightly increased operating time (+5 minutes, 95% confidence interval (CI) +4 to +6, p < 0.001) and post-operative time in the operating room (+5 minutes, 95% CI +2 to +8, p < 0.001) compared with spinal anaesthesia. General anaesthesia was associated with a shorter LOS (hazard ratio (HR) 1.28, 95% CI 1.22 to 1.34, p < 0.001). Any adverse event (odds ratio (OR) 1.21, 95% CI 1.10 to 1.32, p < 0.001), thromboembolic events (OR 1.90, 95% CI 1.24 to 2.89, p = 0.003), any minor adverse event (OR 1.19, 95% CI 1.09 to 1.32, p < 0.001), and blood transfusion (OR 1.34, 95% CI 1.22 to 1.49, p < 0.001) were associated with general anaesthesia. General anaesthesia was associated with decreased rates of urinary tract infection (OR 0.73, 95% CI 0.62 to 0.87, p < 0.001). There was no clear overall advantage of one type of anaesthesia over the other, and surgeons should be aware of the specific risks and benefits associated with each type. Cite this article: Bone Joint J 2015; 97-B:689–95

Background. It is unclear which form of anaesthesia is the most favourable in primary total hip replacement (THR) surgery. A recently published systematic review of modern anaesthesia techniques in primary THR surgery (Macfarlane 2009) was not able to show any convincing benefit of regional or general anaesthesia. One retrospective study that examined anaesthesia and leg length (Sathappan 2008), found an increased incidence of leg length difference > 5 mm in those patients who were operated with regional anaesthesia. Our department used a mini invasive approach in supine as standard procedure in THR. The type of anaesthesia that is chosen is up to the individual anaesthetist. Purpose. We wanted to see if there was any correlation between type of anaesthesia and leg length, total time spent in theatre and recovery room, postoperative hospital stay, blood loss or operating time in primary THR surgery with a mini invasive approach in supine. Materials and Methods. Our study was a retrospective study of 170 primary THR patients. All patients received an uncemented Corail stem and a cemented Marathon cup. Patients with abnormal anatomy, BMI > 46, simultaneous removal of internal fixation or incomplete data were excluded in the analysis. Radiograpic leg length was measured using the inter teardrop line and the lesser trochanter. Results. 99 patients were operated on with spinal anaesthesia and 71 with total intravenous anaesthesia (TIVA). There were 65% women in both groups. Average age was 74 years (32–95) in the spinal anaesthesia group and 67 years (38–93) in the TIVA group. We found no significant difference in the average operating time (spinal 65 min, TIVA 64 min), drop in haemoglobin to the first postoperative day (spinal 16%, TIVA 16%), postoperative hospital stay (Spinal 1.4 days, TIVA 1.4) or in transfusion rate (spinal 1%, TIVA 1.4%). We found a significant difference in the proportion of patients with a leg length difference of more than 7 mm (Spinal 22%, TIVA 6%, p = 0.02) and the average total time spent in theatre and post-operative department (spinal 325 min, TIVA 293 min, p < 001). Discussion. The study is retrospective and is therefore fettered by the limitations inherent in such a study. Our study seems to confirm the earlier findings that the type of anaesthesia can affect leg length in primary THR. It is speculated that spinal anaesthesia has a more unpredictable effect on muscular tension which could explain this

Background. The degree of postoperative pain is usually moderate to severe following Total Hip Arthroplasty (THA). Comfort and lack of pain are important for optimal mobilization and earlier home discharge. Aim. To evaluate the efficacy and safety of Ropivacaine, a long- acting local anaesthetic, when infiltrated in the wound at the end of operation of THA. Methods. Seventy patients, 39 women and 31 men, ASA I-III, underwent Total Hip Arthroplasty in our clinic from January 2008 to June 2009. Patients were randomized into two groups. In group A, a solution of 100 ml Ropivacaine 2mg/ml (Naropeine 0,2%) was infiltrated in the deep tissues (capsule, gluteus medius, gluteus maximus and rotators) (50 ml) while the fascia, subcutaneous tissues and skin were infiltrated with the remaining 50ml. Group B was the control group. All patients received standardized general anesthesia or spinal anesthesia and a PCA morphine using a self-administered pain pump was applied in the recovery room for 48 hours. All patients took 1gr x 3 Apotel i.v., 40mg x2 Dynastat i.v., and 4mg x2 Zofron i.v. for 48 hours postoperative. Pain scores with Visual Analogue Scale (0–10) at 1, 2, 4, 8, 12, 24 and 48 hours postoperatively, time to the first analgesic requirement and side effects were recorded. Results. There were no significant differences in demographic characteristics of the patients and duration of the surgery between two groups. Morphine consumption was statistically significantly lower in group A for the first 48 hours, resulting in a lower frequency of nausea, itching and sedation. Postoperative pain levels at rest and during mobilization were statistically significantly lower in group A while median hospital stay was similar in both groups. Conclusion. Operative wound infiltration with ropivacaine reduces pain and the requirement for analgesics after hip replacement, leading to faster postoperative mobilization

Background. We compared pain relief after total hip arthroplasty using periarticular intraoperative injection along with single dose post operative injection of local anesthetic (THA) with the well-established practice of epidural infusion. Methods. 70 patients undergoing elective THA under combined spinal anaesthesia were randomly assigned to receive either (1) continuous epidural infusion (group B) or (2) infiltration around the hip joint with a mixture of 100 ml of bupivacaine (2 mg/ml) + 1ml ketorolac (30mg/ml) and 0.5ml epinephrine (1mg/ml) at the conclusion of surgery combined with one postoperative intraarticular injection of 20 ml. of Bupivacaine 0.5% + 1ml ketorolac (30mg/ml)+ 0.5 ml. epinephrine (1mg/ml) through an intraarticular catheter (group A). All patients received acetoaminophen 1gm 8 hourly for 72 hrs and injection ketoralac 30mg every 6 hourly IV(15mg if >65 yr 30mg if <65 yr). Breakthrough pain in any group (VAS >7) was treated by injection fentanyl 20 μg bolus at 10 min. interval till VAS reduced to < 4. If VAS 4–7 injection tramadol 50mg IV was given if VAS continued to be >4 after 15 min. then injection fentanyl 20 μg bolus was given at 10 min interval till VAS <4. Results. Narcotic consumption was significantly reduced in group A compared to group B (p=0.007). Pain levels at rest and during mobilization were similar in both groups during first 24 hrs but significantly reduced in group A after cessation of treatment. Interpretation. Wound infiltration combined with intraarticular injection of local Anaesthetics provides good pain relief for patients undergoing THA

Aims

Posterior column plating through the single anterior approach reduces the morbidity in acetabular fractures that require stabilization of both the columns. The aim of this study is to assess the effectiveness of posterior column plating through the anterior intrapelvic approach (AIP) in the management of acetabular fractures.

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The aim of this study was to compare the early postoperative mortality and morbidity in older patients with a fracture of the femoral neck, between those who underwent total hip arthroplasty (THA) and those who underwent hemiarthroplasty.

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The aim of this study was to investigate the association between additional rehabilitation at the weekend, and in-hospital mortality and complications in patients with hip fracture who underwent surgery.

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The use of multimodal non-opioid analgesia in hip fractures, specifically acetaminophen combined with non-steroidal anti-inflammatory drugs (NSAIDs), has been increasing. However, the effectiveness and safety of this approach remain unclear. This study aimed to compare postoperative outcomes among patients with hip fractures who preoperatively received either acetaminophen combined with NSAIDs, NSAIDs alone, or acetaminophen alone.

Introduction. The purpose of this study was to compare the clinical outcomes and complications following bilateral simultaneous total knee arthroplasty in high body mass index (BMI) patients(>30kg/m. 2. ) to those of patients with a BMI<30 kg/m. 2. . Materials and Methods. Using data from an academic arthroplasty database and review of clinic charts we obtained health related quality of life (SF-12), and disease specific functional outcome scores (WOMAC or Oxford Knee Score). We also assessed length of hospital stay, ASA grade and transfusion requirements. Sixty six patients had a BMI<30 and 151 patients had a BMI>30. Results. Most cases were performed under combined spinal/epidural anaesthesia. We could find no appreciable difference in length of hospital stay, ASA grade or transfusion requirements between the two subgroups. Furthermore, were unable to detect any significant differences in post operative SF-12, WOMAC or Oxford Knee scores. There appeared to be no significant increase in the rate of medical complications between the two subgroups, and while there may have been a slight trend towards higher procedure related complications in the high BMI group, this did not reach statistical significance. Conclusions. In our study increased BMI appears to have no negative effects as regards functional outcomes, hospital stay or transfusion requirements for bilateral sequential knee arthroplasty. However there may be an increase in procedural/device related complications which could result in increased revision rates in these patients

Patients undergoing total knee arthroplasty (TKA) experience significant postoperative pain. This impedes early mobilization and delays hospital discharge. A prospective audit of 1081 patients undergoing primary TKA during 2008 was completed. All patients followed a programme including preoperative patient education, pre-emptive analgesia, spinal/epidural anaesthesia with propofol sedation, intra-articular soft tissue wound infiltration, postoperative high volume ropivacaine boluses with an intra-articular catheter and early mobilization. Primary outcome measure was length of stay. Secondary outcomes were verbal analogue pain scores on movement, time to mobilization, nausea and vomiting scores, urinary catheterization for retention, need for rescue analgesia, range of motion at discharge and six weeks postoperatively. The median day of discharge was postoperative day four. Median pain score on mobilization was three for first postoperative night, day one and two. 35% of patients ambulated on the day of surgery and 95% of patients within 24 hours. 79% patients experienced no nausea or vomiting. Catheterization rate was 6.9%. Rescue analgesia was required in 5% of cases. The median day of discharge was postoperative day four. Median range of motion was 85° on discharge and 93° at six weeks postoperatively. This comprehensive care plan provides satisfactory postoperative analgesia allowing early safe ambulation and discharge

Introduction. Tranexamic acid is an inhibitor of fibrinolysis that blocks the lysine-binding site of plasminogen to fibrin, and thereby decreases blood loss in patients undergoing surgery. Aims and objectives. A prospective, randomized, double-blind study was done on 100 patients undergoing primary cemented Unilateral Total Knee Arthroplasty to determine the effect of tranexamic acid on intra- and postoperative blood losses and on the transfusions requirements. Material and Methods. 100 patients undergoing unilateral cemented total knee Arthroplasty for osteoarthritis were enrolled for the study. All total knee replacement was done under combined spinal epidural anaesthesia with the use of tourniquet. 100 patients were randomized to tranexamic acid (15 mg/kg) given as a bolus intravenous injection or placebo (normal saline) given intravenously, 15 minutes before the release of tourniquiet. The blood loss (at removal of the drain 24 hours after the operation) and the number of blood transfusions required were recorded. The patients were screened for deep venous thrombosis with bilateral compression Ultrasonography using Colour Doppler imaging on the tenth postoperative day. The Hemoglobin level was measured preoperatively and on the 3rd postoperative day. The D-dimer levels were measured preoperatively and 24 hrs postoperatively. Results. Patients receiving tranexamic acid had a mean postoperative blood loss of 175 ml(range, 130–310ml) versus 330 ml (range, 210–460ml) (p value<0.05), and a total need for 3 blood transfusions versus 15. Only 3 out 50 patients in tranexamic acid group required blood transfusion whereas 12 out of 50 patients in the placebo group required transfusion. In the group receiving placebo the mean fall in hemoglobin was 2.1g/dl (range, 1.5–3.2) and in the group treated with tranexamic acid 1.3 g/dl (0.9–2) (p<0.05). At 24 hrs postoperatively, mean plasma D-dimer concentration in the Tranexamic group was half of that in the control group. No patient in either group had any evidence of deep vein thrombosis on bilateral compression Ultrasonography using Colour Doppler imaging done on the tenth postoperative day. Conclusion. Tranexamic acid 15 mg/kg given as a single bolus dose reduces blood loss, and transfusion requirements in unilateral primary cemented total kneearthroplasty without any increased risk of thrombus formation

Aims

The aim of this study was to assess whether it is possible to predict the mortality, and the extent and time of neurological recovery from the time of the onset of symptoms and MRI grade, in patients with the cerebral fat embolism syndrome (CFES). This has not previously been investigated.

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This study sought to determine the proportion of older adults with hip fractures captured by a multicentre prospective cohort, the World Hip Trauma Evaluation (WHiTE), whether there was evidence of selection bias during WHiTE recruitment, and the extent to which the WHiTE cohort is representative of the broader population of older adults with hip fractures.

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Low haemoglobin (Hb) at admission has been identified as a risk factor for mortality for elderly patients with hip fractures in some studies. However, this remains controversial. This study aims to analyze the association between Hb level at admission and mortality in elderly patients with hip fracture undergoing surgery.

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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.

Aims

Tibial plateau fractures are serious injuries about the knee that have the potential to affect patients’ long-term function. To our knowledge, this is the first study to use patient-reported outcomes (PROs) with a musculoskeletal focus to assess the long-term outcome, as compared to a short-term outcome baseline, of tibial plateau fractures treated using modern techniques.

Objectives

Osteochondral injuries, if not treated adequately, often lead to severe osteoarthritis. Possible treatment options include refixation of the fragment or replacement therapies such as Pridie drilling, microfracture or osteochondral grafts, all of which have certain disadvantages. Only refixation of the fragment can produce a smooth and resilient joint surface. The aim of this study was the evaluation of an ultrasound-activated bioresorbable pin for the refixation of osteochondral fragments under physiological conditions.

Objectives

To determine the morbidity and mortality outcomes of patients presenting with a fractured neck of femur in an Australian context. Peri-operative variables related to unfavourable outcomes were identified to allow planning of intervention strategies for improving peri-operative care.

Techniques for fixation of fractures of the lateral malleolus have remained essentially unchanged since the 1960s, but are associated with complication rates of up to 30%. The fibular nail is an alternative method of fixation requiring a minimal incision and tissue dissection, and has the potential to reduce the incidence of complications.

We reviewed the results of 105 patients with unstable fractures of the ankle that were fixed between 2002 and 2010 using the Acumed fibular nail. The mean age of the patients was 64.8 years (22 to 95), and 80 (76%) had significant systemic medical comorbidities. Various different configurations of locking screw were assessed over the study period as experience was gained with the device. Nailing without the use of locking screws gave satisfactory stability in only 66% of cases (4 of 6). Initial locking screw constructs rendered between 91% (10 of 11) and 96% (23 of 24) of ankles stable. Overall, seven patients had loss of fixation of the fracture and there were five post-operative wound infections related to the distal fibula. This lead to the development of the current technique with a screw across the syndesmosis in addition to a distal locking screw. In 21 patients treated with this technique there have been no significant complications and only one superficial wound infection. Good fracture reduction was achieved in all of these patients. The mean physical component Short-Form 12, Olerud and Molander score, and American Academy of Orthopaedic Surgeons Foot and Ankle outcome scores at a mean of six years post-injury were 46 (28 to 61), 65 (35 to 100) and 83 (52 to 99), respectively. There have been no cases of fibular nonunion.

Nailing of the fibula using our current technique gives good radiological and functional outcomes with minimal complications, and should be considered in the management of patients with an unstable ankle fracture.

We undertook a prospective randomised controlled trial involving 400 patients with a displaced intracapsular fracture of the hip to determine whether there was any difference in outcome between treatment with a cemented Thompson hemiarthroplasty and an uncemented Austin-Moore prosthesis. The surviving patients were followed up for between two and five years by a nurse blinded to the type of prosthesis used.

The mean age of the patients was 83 years (61 to 104) and 308 (77%) were women. The degree of residual pain was less in those treated with a cemented prosthesis (p < 0.0001) three months after surgery. Regaining mobility was better in those treated with a cemented implant (p = 0.005) at six months after operation. No statistically significant difference was found between the two groups with regard to mortality, implant-related complications, re-operations or post-operative medical complications.

The use of a cemented Thompson hemiarthroplasty resulted in less pain and less deterioration in mobility than an uncemented Austin-Moore prosthesis with no increase in complications.