Mortality following revision hip surgery for periprosthetic fracture (PPF) has been reported to be as high as 60% at 5 years. The aim of this study was to determine the mortality rate for PPF revisions, compared to revision for aseptic loosening or infection at our tertiary referral centre.

Revision arthroplasty procedures performed for PPF, aseptic loosening or infection between January 2014 and December 2015 at our institution were identified using a prospectively collected PPF referral database and locally collected NJR data. Comparisons were made between the 3 groups for baseline demographics, admission to higher-level care, length of stay, complications, and Kaplan-Meier failure (mortality) at 1 & 5 years post-operative (with log-rank test for equality).

There were 37 PPF, 71 infected and 221 aseptic revisions. PPF had a higher proportion of females (65% vs. 39% in infection and 53% in aseptic; p = 0.031) and grade 3 and 4 ASA patients (p = 0.006). Median time to surgery from injury for PPF was 8 days (95% CI, 6–16). Single-stage procedures were performed in 84% of PPF, 42% of infection and 99% of aseptic revisions (p < 0.001). 19% of PPF revisions required HDU admission, 1% in the aseptic group and none in the infection group (p<0.001). Median length of stay was significantly different (PPF 10; infection 14; aseptic 8 days (p < 0.001). The Kaplan-Meier estimate of 1-year mortality were: PPF = 0%; infection = 2.8% (0.7–11.1%); aseptic = 0.9% (0.2–3.5%). 5-year mortality estimates were: PPF = 17.1% (8–34%), infection = 8.7% (4–18.3%), aseptic = 12% (8.4–17%). Log-rank test of equality was not significant, p=0.833.

Despite the PPF group having an average delay to surgery of 8 days, higher ASA grades and more admissions to HDU there was no significant difference in mortality rates between the groups at 1 and 5 years postoperatively. Using a coherent MDT approach with dedicated healthcare professionals this service demonstrates a low post operative mortality rate which merits further investment and development.

Introduction

Lateral epicondylitis, also known as “tennis elbow,” is a degenerative disorder of the common extensor origin of the lateral humeral epicondyle. The mainstay of treatment is non-operative and includes physiotherapy, activity modification, bracing, nonsteroidal anti-inflammatory drugs, and injections. There is a subgroup of patients however who do not respond to non-operative measures and require operative intervention.

The most important determinant in the treatment of malleolar fractures is stability. Stable fractures have an intact deep deltoid ligament and do not displace with functional treatment. If the deep deltoid/medial malleolar complex is disrupted, the talus is at risk of displacement. Weber (2010) showed that weightbearing radiographs predicted stability in patients with undisplaced ankle fractures.

We developed clinical criteria for potential instability and applied them to a prospective series of patients. Criteria included: medial clear space of < 4mm; medial tenderness, bruising or swelling; a fibular fracture above the syndesmosis; a bimalleolar or trimalleolar fracture; an open fracture; a high-energy fracture mechanism. A consecutive, prospectively documented series of 37 patients chose functional brace treatment of potentially unstable fractures. Weightbearing radiographs were performed in the brace before treatment, and free of brace at clinical union (6–9 weeks in all patients). Patients were encouraged to bear full weight and actively exercise their ankles in the brace.

All fractures healed without displacement. The risk of displacement was 0% (95% CI 0–11.2%). This preliminary series gives support for the use of weightbearing radiographs to guide treatment of undisplaced ankle fractures.