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Jane Fitzpatrick,1,2 Christen Richardson,3 Ianiv Klaber,4 Martin D Richardson1 1Centre for Health and Exercise Sports Medicine, School of Health Sciences, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, VIC, Australia; 2Joint Health Institute, Melbourne, VIC, Australia; 3Medical School, College of Health and Medicine, Australian National University, Acton, ACT, Australia; 4Orthopaedic Surgery Department, School of Medicine, Pontifical Catholic University of Chile, Santiago, ChileCorrespondence: Jane FitzpatrickCentre for Health and Exercise Sports Medicine, School of Health Sciences, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Level 7, Allan Gilbert Building, 161 Barry Street, Melbourne, VIC, AustraliaEmail jane.fitzpatrick@unimelb.edu.auBackground/Hypothesis: Adhesive capsulitis of the shoulder results in pain and restricted movement of the glenohumeral joint. Hypothesis: There would be a difference in active range of movement in the affected shoulder of patients with adhesive capsulitis after receiving a series of injections of collagenase Clostridium histolyticum (CCH) compared to placebo.Methods: This study reports the results from a single site that was part of a 321-participant, multicenter, double-blind, prospective parallel-group, randomized controlled clinical trial. Inclusion criteria: over 18 years of age, unilateral idiopathic adhesive capsulitis for > 3 months, but < 12 months. Exclusion criteria: recent physical therapy, injections, subacromial impingement, calcific tendonitis or glenohumeral joint arthritis in the affected shoulder. Subjects were randomized 3:1 to receive CCH 0.58 mg or placebo under ultrasound guidance. Injections were on days 1, 22, and 43. The primary outcome measure was a functional assessment of active range of movement.Results: Overall, 37 patients were screened, 26 subjects were excluded, and 11 subjects were randomly assigned to the treatment group (n=9) or the control group (n=2). Both control and treatment groups showed improvement in ROM between baseline and day 95. In the treatment group, AROM improved from the baseline of 272.89° (SD 86.25) to 462.11° (SD 96.89) and the control group from 246.00° (SD 5.66) to 451.50° (SD 50.20) at day 95 with no statistical difference between groups p=0.78. Site data were in line with the whole study findings. Treatment-related adverse events at the injection site, including haematoma (bruising) and localised pain and swelling, were common.Conclusion: Although the participants showed improvement in function, statistical significance was neither reached in the site nor the overall study cohort. Given the adverse events and the potential risks of the procedure, we would not recommend this drug for the treatment of adhesive capsulitis of the shoulder.Level of Evidence: 2, cohort from one site of RCT.Keywords: adhesive capsulitis, frozen shoulder, collagenase

Ligamentum teres (LT) tear is a recognized cause of hip pain. Debridement of tears and capsule plication has shown satisfactory results. However, a group of patients with complete tears do not improve after debridement and physiotherapy. The purpose of this work was to describe the senior author's technique and clinical results for the early series of LT reconstructions. Retrospective analysis of prospectively collected data. Patients who underwent isolated LT reconstruction between 2013 and 2018. All the patients had previous debridement of a completely torn LT, capsule plication and rehabilitation. Patients who had any other associated procedure during LT reconstruction surgery and dysplastic acetabular features were excluded. Demographic and clinical data was reviewed. Complications, type of graft and modified Harris hip scores (mHHSs) were recorded preoperatively and at 1-year follow-up. Fifteen LT reconstructions were performed during the study period. Six were excluded (as they had additional procedures performed during surgery) and nine patients aged a mean 30 (range: 22–48) years old were included. The patients had a mean of 2 (range: 1–4) prior surgeries. At minimum 12 months (range: 12–24) 9/9 patients reported reduction of pain and instability symptoms with mHHSs of 84.2 (73.7–100) versus 51.7 (36.3–70.4) preoperatively (P  = 0.00094). Three patients (of the total cohort of 15) underwent second-look arthroscopy (11–22 months after reconstruction). None of these patients underwent total hip replacement at a mean of 4 (range: 1–6) years. Arthroscopic LT reconstruction improved function and pain in patients with persistent pain and instability after resection of the LT. [ABSTRACT FROM AUTHOR]

Introduction: Every year about 9 million fragility fractures occur worldwide. 80% of these fragility fractures are undiagnosed or untreated. In order to close the gap of diagnosis and treatment of osteoporosis, Fracture Liaison Services (FLS) were created. Currently there are no clinical guidelines, protocols or FLS in Chile for diagnosing or treating fragility fractures. Objective: To describe the implementation of the first FLS in Chile, its inclusion criteria, patient enrolment, referrals to other healthcare members and treatment adherence during the first year. Methods: This FLS operation was based in a university affiliated health care network compound by 2 hospitals. The Best Practice Framework guidelines of the International Osteoporosis Foundation campaign "Capture the Fracture" (CTF) were applied. A nurse practitioner worked as coordinator for the program. From May 2020 to April 2021 all the patients diagnosed with a fragility fracture in the emergency rooms were contacted and invited to participate. Demographical data, anatomical site of the fracture, previous fractures, treatment prescribed and adherence, and mortality were all recorded. Patients with pathological fractures and active cancer were excluded from the FLS. Results: During the first year of this FLS, 443 patients were diagnosed with fragility fractures and met the inclusion criteria, 177 patients (40%) accepted to participate in the program. The average age of the participants was 73.8±13.3 years and 84% were female. Hip fractures were more frequent (67/177). Of the 177 patients, 95 reported previous fragility fractures, 32 had osteoporosis diagnosed, 20 patients reported past or current treatment for osteoporosis. At the 4-month follow-up 62% had received vitamin D/calcium supplementation and 50% of the patients with prescription for antiosteoporotic drugs had received them. Secondary referral to Endocrinology was required in 28% of the cases due to secondary osteoporosis or subsequent fractures occurred while under antiosteoporotic treatment. After 6 months of operation the FLS was listed as a recognized FLS by CTF. Conclusion: During the first year of operation of this FLS 40% of the candidates were enrolled and half of the participants had received anti osteorotic treatment 4 months after their fracture. The FLS was able to manage 72% of the patients without the need of secondary referrals. There is still much work to do closing the gap of treatment in Chile and developing local guidelines. [ABSTRACT FROM AUTHOR]

Background: Fragility fractures have significant sequelae, including pain, loss of mobility, and increased risk of mortality. Fracture liaison services (FLS) represent a coordinated, interdisciplinary approach to secondary prevention and reduce mortality., Purpose: To investigate the effectiveness and patient outcomes regarding readmission and mortality of a newly developed, nurse practitioner (NP) coordinated FLS in Chile., Methodology: Retrospective longitudinal analysis of 214 patients who agreed to participate in a FLS was conducted. Variables studied include patient age, gender, anatomical fracture site, dual x-ray absorptiometry scans, medication, readmission information, and mortality. Demographics and clinical data were collected and analyzed with bivariate and multivariate statistics. Kaplan-Meier curves and log-rank tests were performed to compare survival curves between those who did and did not participate in the FLS., Results: The study sample was predominantly female (85%) with a mean age of 76 (SD: 12; range 41-101) years. The most frequently noted fracture sites were hip (n = 167), wrist (n = 132), and spine (n = 72). At one-year follow-up, the FLS group had a significantly lower mortality (5%, 10 patients) than those who did not participate in the program (12% [N = 50], p = .005). The Kaplan-Meier analysis indicated that patients who participated in the FLS had significantly better survival rates than those who did not participate., Conclusions: Significantly improved survival rates were observed in FLS patients. Chile's first FLS demonstrated improved patient outcomes, specifically a reduced mortality in patients who were enrolled in the FLS., Implications: The NP role was fundamental in the screening, diagnosis, and treatment of patients with osteoporosis., Competing Interests: Competing interests: The authors report no conflicts of interest., (Copyright © 2024 American Association of Nurse Practitioners.)

Background: Osteoporosis increases the risk of periprosthetic fracture and loosening in hip arthroplasty. Many methods have been proposed to assess bone quality in X-rays, including both qualitative such as the Dorr classification and quantitative such as the Calcar-Canal Ratio (CCR) and Cortical-Thickness index/Canal-Bone ratio (CTI/CBR). The Canal-Diaphysis ratio (CDR) has been described as a predictor for hip fragility fractures; however, its relationship with bone mineral density (BMD) has not been described. The purpose of this study was to evaluate the correlation of the Dorr classification, CCR, CTI/CBR, and CDR with BMD of the proximal femur in patients without hip fracture., Methods: Forty-seven patients over 45 years of age who had less than 6 months between radiographs and dual-energy X-ray absorptiometry were evaluated. Measurements of CCR, CBR, CDR, and Dorr classification were performed in all radiographs by 2 independent observers., Results: The CDR had a high correlation (r = 0.74, P=<0.01) with BMD, whereas the CTI/CBR had a moderate correlation (r = 0.49, P=<0.01), and the CCR had no correlation with BMD (r = 0.06, P = .96). When evaluating the receiver operating characteristic curve, CDR showed the best performance (area under curve [AUC] = 0.75) followed by CBR (AUC = 0.73) and CCR (AUC = 0.61). The optimal cutoff value for the CDR was 0.49, with 100% sensitivity and 58% specificity. The inter- and intra-observer variability was good for all methods. No differences were found between Dorr classification of patients who had or did not have osteoporosis., Conclusion: Of all the analyzed methods, the CDR was found to have the best correlation with BMD. This study proposes the use of CDR as a tool for assessing bone quality when deciding the implant fixation method in hip arthroplasty., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: The aim of this study was to assess the difference in success rates of closed reduction in septic and aseptic revision total hip arthroplasty (THA) performed with a dual mobility (DM) implant. Our objective was to answer the following questions: (1) Is there a difference in success rates of closed reduction between septic and aseptic revision THA with a DM implant? (2) Is closed or open reduction more successful in preventing re-dislocation?, Methods: Between January 2009 and October 2021, 924 revisions were performed with a DM implant. All patients presenting to our institution with a dislocation following septic or aseptic revision THA using a cemented DM cup were included in this study. We analyzed 106 cases of dislocation in 74 patients. For all patients, we collected reason for revision, and classified index surgery as septic or aseptic., Results: Overall, 106 dislocations occurred (106/924, 11.5%). Thirty-nine cases (52.7%) had a dislocation after a septic exchange THA, while in 35 patients (47.3%), a dislocation occurred after an aseptic rTHA. In 29 patients (39.2%), successful closed reduction under general anesthesia was feasible, while the majority of cases required open reduction. In 31 of these patients (67.4%), open reduction was combined with a revision arthroplasty., Conclusions: In case of DM cup dislocation, there is a low success rate of closed reduction. To prevent re-dislocation, total revision leads to a significantly reduced risk compared to open or closed reduction alone. Careful X-ray analysis for a halo sign showing intra-prosthetic DM cup dislocation is mandatory to avoid futile reduction attempts., Level of Evidence: III., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: Different approaches have been proposed for bacterial identification in patients with a suspected periprosthetic joint infection (PJI). If a one-stage procedure is considered, a higher rate of preoperative bacterial identification can be achieved if biopsy is included in the diagnostic work-up. The performance of open biopsy (OB) in the context of PJI has not been clearly determined yet. The purpose of this study was to determine the value of an OB added to two consecutive culture-negative joint aspirations during PJI workup., Materials and Methods: We retrospectively analyzed the OB data from a single institution. Patients under PJI work-up of the hip or knee with two culture-negative periprosthetic aspirations who underwent OB were included. Sensitivity and specificity were calculated using the musculoskeletal infection society (MSIS) criteria as gold standard. Patients undergoing urgent irrigation and debridement and patients with history of surgery to the affected joint in the prior 6 weeks were excluded., Results: 126 patients were included in this study. 62 (49.2%) patients had prior revisions, 48 of them due to PJI. The sensitivity and specificity of OB was 69.4% and 89.1%, respectively. The OB procedure led to the identification of the causative germ in 50 out of 126 (40%) cases so they could undergo one-stage (septic) exchange., Conclusion: The OB is a valuable resource if preoperative synovial fluid cultures are negative, a high suspicion of infection persists and a one-stage procedure is preferred. It intends bacteria identification and allows surgeons to evaluate prosthetic complications for further surgical procedures., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Every year about 9 million fragility fractures (FF) occur worldwide and 80% of these are underdiagnosed or undertreated. Aiming to close the gap of diagnosis and treatment of osteoporosis, Fracture Liaison Services (FLS) were developed., Aim: To describe the implementation of the first FLS in Chile, its inclusion criteria, patient enrolment, treatment adherence and referrals during the first year., Material and Methods: A FLS was implemented at a health care network composed by two hospitals. The International Osteoporosis Foundation (IOF) guidelines were applied with a nurse practitioner as the coordinator. From May 2020 to April 2021 all patients diagnosed with a FF in the emergency rooms were invited to participate. Patients with pathological fractures and active cancer were excluded. Demographical data, fracture location, previous fractures, treatment and adherence, and mortality were recorded., Results: From 443 patients with a diagnosis of FF, 177 patients (40%) accepted to participate. Their mean age was 74 ± 13 years and 84% (149) were female. Forty eight percent (84) had a lower extremity FF. Hip fractures were the most common (67). Ninety-five patients reported previous FF and 11,2% (20) had received anti-osteoporotic treatment. At four months of follow-up, 62% (50) had received vitamin D and calcium supplementation and 20% (16) of those patients with an indication of anti-osteoporotic drugs, had received them., Conclusions: The implementation of the FLS was successful with a 40% enrolment of patients, receiving certification by the IOF.

Background: Sacral fractures treatment frequently involves both spine and pelvic trauma surgeons; therefore, a consistent communication among surgical specialists is required. We independently assessed the new AOSpine sacral fracture classification's agreement from the perspective of spine and pelvic trauma surgeons., Methods: Complete computerized tomography (CT) scans of 80 patients with sacral fractures were selected and classified using the new AOSpine sacral classification system by six spine surgeons and three pelvic trauma surgeons. After four weeks, the 80 cases were presented and reassessed by the same raters in a new random sequence. The Kappa coefficient (κ) was used to measure the inter-and intra-observer agreement., Results: The inter-observer agreement considering the fracture severity types (A, B, or C) was substantial for spine surgeons (κ= 0.68 [0.63 - 0.72]) and pelvic trauma surgeons (κ= 0.74 (0.64 - 0.84). Regarding the subtypes, both groups achieved moderate agreement with κ= 0.52 (0.49 - 0.54) for spine surgeons and κ= 0.51 (0.45 - 0.57) for pelvic trauma surgeons. The intra-observer agreement considering the fracture types was substantial for spine surgeons (κ= 0.74 [0.63 - 0.75]) and almost perfect for pelvic trauma surgeons (κ= 0.84 [0.74 - 0.93]). Concerning the subtypes, both groups achieved substantial agreement with, κ= 0.61 (0.56 - 0.67) for spine surgeons and κ= 0.68 (0.62 - 0.74) for pelvic trauma surgeons., Conclusion: This classification allows an adequate communication for spine surgeons and pelvic trauma surgeons at the fracture severity type, but the agreement is only moderate at the subtype level. Future prospective studies are required to evaluate whether this classification allows for treatment recommendations and establishing prognosis in patients with sacral fractures., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Introduction: Hip fracture patients have been severely affected by the COVID-19 pandemic; however, the sub acute effects of a concomitant SARS-CoV-2 infection and the outcomes in highly exposed developing countries are still unknown. Our objective is to describe the morbidity and mortality of elderly patients admitted for a hip fracture during the COVID-19 pandemic in Chile, with a minimum 90-day follow-up. Also, to elucidate predictors for mortality and to compare mortality results with the pre-pandemic era., Material and Methods: Multicentric retrospective review of patients admitted for a fragility hip fracture in 3 hospitals during the COVID-19 pandemic, and during the same time in 2019. All clinical information and images were recorded, and patients were followed for a minimum of 90-days. Morbidity and mortality were the primary outcomes. Uni/multivariable models were performed to elucidate predictors for mortality utilizing the Weibull's regression., Results: Three hundred ninety-one cases were included. From the 2020 cohort (162 patients), 24 (15%) had a concomitant SARS-CoV-2 infection. Fourteen patients (58%) tested positive after admission. The COVID-19(+) group had a higher risk of in-hospital, 30-day, and 90-day mortality (p < 0.001). They also had a prolonged hospital stay and presented with more complications and readmissions (p < 0.05). Only COVID-19(+) status and older age were independent predictors for mortality with a HR = 6.5 (p = < 0.001) and 1.09 (p = 0.001), respectively. The 2020 cohort had twice the risk of mortality with a HR = 2.04 (p = 0.002) compared to the 2019 cohort. However, comparing only the COVID-19 (-) patients, there was no difference in mortality risk, with a HR = 1.30 (p = 0.343)., Discussion: The COVID-19 pandemic has significantly affected healthcare systems and elderly patients., Conclusions: Hip fracture patients with a concomitant SARS-CoV-2 virus infection were associated with increased morbidity and mortality throughout the first 3 months. COVID-19 status and older age were significant predictors for mortality. Efforts should be directed into nosocomial infection reduction and prompt surgical management., Level of Evidence: Level III., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2021.)

Background: A new AO classification for intertrochanteric fractures was recently published; no studies have evaluated its inter- and intra-observer agreement., Methods: Six evaluators (three hip subspecialists and three residents) assessed radiographs of 68 intertrochanteric fractures; fractures were classified using the original and the new AO classifications. The cases were displayed in a random sequence after a six-week interval for repeat evaluation. We used the Kappa coefficient (k) to determine inter- and intra-observer agreement., Results: Inter-observer agreement was slight (k = 0.128 [0.092-0.170]) using the original and fair (k = 0.250 [0.186-0.327]), with the new AO classification. Orthopedic residents exhibited better agreement than hip surgeons using the original classification (k = 0.302 [0.210-0.416] and k= -0.018 [-0.058-0.029], respectively) and the new classification (k = 0.388 [0.294-0.514] and k = 0.109 [0.031-0.192], respectively). Using both classifications as dichotomous variables (stable or unstable patterns), the agreement was slight (k = 0.158 [0.074-0.246]) using the original classification and moderate (k = 0.425 [0.308-0.550]) with the new AO classification., Intra-Observer: The agreement was fair using the original (k = 0.350 [0.278-0.424]) and the new (k = 0.295 [0.239 to 0.353]) AO classifications, respectively. Residents had better agreement than hip specialists using the original (k = 0.405 [0.303-0.512]) versus (k = 0.292 [0.193-0.293]) and the new classification (k = 0.449 [0.370 to 0.528] versus k = 0.129 [0.064 to 0.208])., Conclusion: The inter-observer agreement using the new AO classification was significantly better than using its original version. Also, the new AO classification system allowed better agreement when distinguishing stable from unstable patterns., Competing Interests: Declaration of Competing Interests The authors of this article declare they have no Conflict of Interest to disclose, (Copyright © 2020. Published by Elsevier Ltd.)

Purpose: Deep vein thrombosis (DVT) is a common complication in hip fracture patients, associated with significant morbidity and mortality. Research has focused on postoperative DVT, with scant reports on preoperative prevalence. The aim of this study was to describe the prevalence of preoperative DVT in patients accessing medical care ≥ 48 h after a hip fracture., Methods: We included elderly patients admitted ≥ 48 h after sustaining a hip fracture, between September 2015 and October 2017. Patients with a previous episode of DVT, undergoing anticoagulation therapy, with pathologic fractures or undergoing cancer treatment were excluded. Of 273 patients, 59 were admitted at least 48 h after the fracture. DVT screening by Doppler ultrasound of both lower extremities was carried upon hospital admission. We recorded age, sex, Charlson comorbidity index and ASA score, fracture type, time since injury, time from admission to surgery and total length of hospital stay., Results: We studied 41 patients, 79 (± 10.34) years old. The delay from injury to admission was 120 h (48-696 h). Seven patients (17.1%) had a DVT upon admission. There were no significant differences between patients with and without DVT, regarding time from admission to surgery or the total length of the hospital stay., Conclusions: The prevalence of DVT in patients admitted ≥ 48 h after a hip fracture was 17.1%. The diagnosis and management of DVT did not increase time to surgery or hospital stay. Our results suggest routine screening for DVT in patients consulting emergency services ≥ 48 h after injury.

Background: Osteomyelitis, particularly cases involving the foot and ankle, is a challenging situation that frequently leads to amputations and major sequelae. Targeted antibiotics treating an identified pathogen are key to a successful outcome; however, traditional culture methods for bone tissue have poor sensitivity. This study prospectively compared a novel method for obtaining and processing infected bone tissue with the standard technique., Methods: 107 patients presenting with a diagnosis of osteomyelitis of the foot and ankle between 2008 and 2017 were prospectively included. Diagnosis was done according to clinical, laboratory and imaging findings. We obtained paired samples of bone tissue from all patients; they were processed through a usual culture method (UCM), but they were also morselized and seeded into pediatric blood culture bottles (PBCBs). We compared the culture yield and the number of agents detected using both the McNemar and the Mann-Whitney tests, respectively., Results: We studied 107 patients (63 with diabetic foot infection and 44 with nondiabetic osteomyelitis). The causative agent was identified in 60.7% of cases using the UCM and in 97.2% of cases using PBCBs (p < 0.001). We detected a mean of 1.05 ± 1.03 bacteria using the UCM and 1.67 ± 0.92 bacteria using PBCBs (p < 0.01)., Conclusion: Cultures using morselized bone seeded in PBCBs identified the causative agent in a significantly larger percentage than the UCM. Additionally, this method identified a larger number of pathogen agents. A better agent identification method has advantages such as identifying more specific antibiotic treatment in these cases., (Copyright © 2019 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Introduction. Nasal and skin colonization by methicillin-resistant Staphylococcus aureus (MRSA) are linked to a higher incidence of infection after total joint replacement. The prevalence of colonization is poorly defined in Latin American countries. Aim. The aim of the present study was to determine the prevalence of MRSA colonization in the nostrils and groin using real-time polymerase chain reaction (RT-PCR) in patients undergoing total hip arthroplasty (THA). Methodology. In this cross-sectional study, 146 patients undergoing THA between December 2015 and March 2017 in a tertiary-care university-affiliated hospital in Chile were screened for MRSA colonization before the procedure using RT-PCR independently in the nostrils and groin. Risk factors for colonization were documented. Results. Seven of the 146 (5 %) patients undergoing THA were carriers of MRSA in the nostrils and/or the groin. Recent antibiotic use was identified as a risk factor for colonization, OR=4.86 [95 % confidence interval (CI): 1.56-13.96]. Patients reporting at least one of the seven surveyed risk factors had an OR of 2.39 (95 % CI: 0.37-25.77) for colonization. MRSA colonization frequency was twofold higher in the groin as opposed to the nostrils ( P =0.014). Conclusion. Five percent of the patients undergoing THA were identified as carriers of MRSA. Recent antibiotic use is a relevant risk factor for MRSA colonization in patients undergoing primary total hip arthroplasty.

Background: Periprosthetic joint infection (PJI) is a severe complication with increasing incidence. However, we are not aware of any robust data on patients having PJI at the same time in ≥2 joints that had undergone total joint arthroplasty, referred to as synchronous PJI throughout this article. The aims of this study were to investigate the probability of the development of synchronous PJI of another prosthetic joint and to identify possible clinical risk factors for the development of synchronous PJI. In addition, we aimed to determine whether routine aspiration of all other prosthetic joints was warranted after a diagnosis of PJI in a single joint., Methods: A total of 2,532 septic revision procedures were performed during the study period. In the final analysis, 644 patients (26 with synchronous PJI and 618 with non-synchronous PJI) with 1,508 prosthetic joints were included. The mean age (and standard deviation) was 71 ± 9.6 years. Using bivariate analyses, we calculated the odds of synchronous PJI as a function of various demographic and clinical variables., Results: A suspicious clinical presentation of the non-primary joint had the strongest association with synchronous PJI (odds ratio [OR], 58.5 [95% confidence interval (CI), 22.4 to 152.8]). Additional associations with synchronous PJI were detected for a history of neoplasia (OR, 12 [95% CI, 3.9 to 37.2]), the use of immune-modulating therapy (OR, 9.5 [95% CI, 3.4 to 26.2]), the presence of systemic inflammatory response syndrome or sepsis (OR, 8.4 [95% CI, 2.8 to 25]), and having ≥3 prosthetic joints (OR, 3.0 [95% CI, 1.37 to 6.64])., Conclusions: Synchronous PJI is a rare but very serious complication and every prosthetic joint should be investigated meticulously. Suspicious clinical presentation, a history of neoplasia, sepsis, immune-modulating therapy, and ≥3 prosthetic joints were identified as risk factors and should increase the physician's vigilance. In the case of PJI, aspiration of each joint that had undergone total joint arthroplasty should be considered., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: Recalcitrant greater trochanteric pain is increasingly recognized as an indication for surgical intervention. The arthroscopic approach has become rapidly more common than the open alternative., Hypothesis: Patients undergoing radiofrequency microdebridement (RFMD) as an adjunct to arthroscopic gluteal bursectomy (AGB) and iliotibial band release (ITBR) will experience better functional improvement than AGB and ITBR alone at 1 year., Study Design: Randomized controlled trial; Level of evidence, 2., Methods: A total of 33 patients with failed nonoperative treatment of gluteal tendinopathy were randomly allocated to undergo AGB/ITBR or AGB/ITBR + RFMD. Full-thickness tears were excluded. The primary outcome measure was the modified Harris Hip Score (mHHS) at 52 weeks. Secondary outcome measures included the mHHS, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), visual analog scale (VAS) for pain, and 12-item Short Form Health Survey (SF-12), which were evaluated at 0, 6, 12, 24, and 52 weeks. Statistical significance was defined as P < .05., Results: A total of 33 participants (33 hips; 30 female and 3 male; mean age, 58 years) were randomized; 16 patients underwent AGB/ITBR + RFMD, and 17 underwent AGB/ITBR. Participants' functionality improved in both groups at all time intervals. The mean mHHS score improved from 57.49 ± 10.61 to 77.76 ± 18.40 ( P = .004) and from 58.98 ± 12.33 to 79.96 ± 18.86 ( P = .001) at 52 weeks in the AGB/ITBR and AGB/ITBR + RFMD groups, respectively, although there was no statistically significant difference between groups. There were no device-related adverse events., Conclusion: AGB/ITBR led to significant improvements in patients with recalcitrant gluteal tendinopathy. In this small RCT, the addition of RFMD showed no additional benefit to AGB/ITBR but provided a safe adjunct for the surgical management of recalcitrant gluteal tendinopathy., Registration: NCT01562366 (ClinicalTrials.gov identifier)., Competing Interests: One or more of the authors declared the following potential conflict of interest or source of funding: J.O. has received consulting fees from Medacta and Smith & Nephew. J.F. has been on the medical advisory board for Bioventus Global. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2020.)

Introduction: Surgical instrument contamination during total joint replacement is a matter of major concern. Available recommendations suggest changing suction tips, gloves and avoiding light handle manipulation during the procedure. There is a paucity of data regarding surgical gown contamination. The aim of the present study was to evaluate the contamination rate of surgical gowns (SGs) during total hip arthroplasty (THA) and secondarily compare it with other orthopedic procedures., Materials and Methods: One hundred and forty surgical gowns (from 70 surgeries) were screened for bacterial contamination using thioglycolate (a high-sensitivity culture broth). The THA contamination rate was compared with those of knee and spine procedures. Controls were obtained at the beginning of every surgery and from the culture broth. The procedure's duration and the level of training of the surgeon were evaluated as potential risk factors for contamination., Results: Bacterial contamination was identified on 12% of surgical gowns (22% of surgical procedures). The contamination rate during THA was 4.1% (2% in primary THA and 8.3% in revisions) vs 21.67% during other surgeries (spine and knee) (OR 6.15, p = 0.012). There were no contaminated SGs during THAs performed in ≤ 2 h (0/33 SGs) vs 7.5% (3/40) for THAs that took ≥ 2 h (p = 0.25)., Conclusion: There was a high rate of SG contamination during orthopedic procedures that was higher during non-arthroplasty procedures and prolonged THAs. There were no contaminated surgical gowns in THAs under 120 min, efforts should point keeping primary THAs under this cutoff time. As a general recommendation, SGs should be changed every time there is concern about potential contamination.

Background: Although 2-stage revision is still considered the gold standard for surgical management of periprosthetic joint infection (PJI), 1-stage revision has been reported to be as effective. Long-term reports for 1-stage revision in hip PJIs are lacking., Methods: We reviewed our 10-11 years of results of 85 patients who underwent 1-stage exchange of the hip with an antibiotic-loaded bone cemented prosthesis due to PJI to determine the following: (1) What is the infection-free survival? (2) What is the overall survival? and (3) What are the long-term clinical outcomes? All 1-stage revision total hip arthroplasties (THAs) for infection between January 2006 and December 2007, with a minimum 10-year follow-up (range 10-11), were included in this retrospective cohort. Patients from another country or patients who were unable to participate were excluded. Eighty-five patients with a hip PJI were available at the last follow-up. Thirty-seven patients died during the 10-year study. Harris Hip Scores were recorded before the surgery and at last follow-up. Failures are reported as infection-related or aseptic., Results: The 10-year infection-free survival was 94% and the surgery-free survival was 75.9%. The Harris Hip Scores improved from 43 (range 3-91) to 75 (range 10-91) (P < .001). The main indication for re-revision after 1-stage exchange was instability (10/20 patients)., Conclusion: One-stage exchange of the hip for PJI is a reliable treatment option with high rate of infection control and long-lasting favorable outcomes., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The management of nondisplaced femoral neck fractures (FNFs) has evolved, with emphasis in radiographic features such as posterior displacement. However, the role of advanced imaging in this scenario is still not well defined. Therefore, our objective is to assess the impact of a computed tomography scan (CT) on interobserver agreement (IA) of fracture classification, posterior tilt measurement, and treatment decisions in nondisplaced FNF in elderly patients., Methods: Eleven patients with a nondisplaced (Garden 1-2) FNF were assessed by six hip surgeons. On a first stage, fracture classification, posterior tilt, and treatment plan (fixation/arthroplasty) were determined only with clinical information and X-rays. On a second stage, a CT was added. The kappa coefficient ( κ) and intraclass correlation coefficient (ICC) were used to determine IA., Results: IA for Garden classification was only slight in X-rays and with the addition of a CT, with a κ = 0.13 (0-0.28) and 0.18 (0.03-0.33), respectively. Conversely, posterior tilt measurement agreement was excellent in both schemes, with an ICC = 0.92 (0.83-0.98) and 0.92 (0.82-0.98). The IA for the proposed treatment was slight with X-rays ( κ = 0.44; 0.29-0.6), but moderate with the addition of a CT scan ( κ = 0.67; 0.52-0.82). Changes in surgical decision where made in 14 of 66 evaluations with an OR = 1.4 (0.62-3.2) for choosing an arthroplasty if a CT was used., Conclusion: IA for fracture classification and posterior tilt evaluation in nondisplaced FNF was not altered by the usage of a CT. There is improvement in treatment agreement when a CT scan is added to conventional imaging, with changes in treatment in 21% of cases.

Background: As the population ages, patients exposed to osteoporotic fractures increase, especially hip fracture, which is the most severe and costly., Aim: To characterize surgical practices in the management of hip fractures in older patients through a nationwide survey of specialized hip surgeons dedicated to the care of these patients., Material and Methods: A survey composed of 32 questions was formulated, including demographic factors, preoperative evaluation, definitive treatment, and postoperative management. It was sent to 140 specialists. 84 of them replied (61%), and 71 answers were included., Results: Eighty six percent of respondents agreed that orthogeriatric management is fundamental in the outcome of these patients, but only 73% had the collaboration of an internist or a geriatrician. Although 97% considered 72 hours or less the ideal time to perform surgery, only 52% of the respondents declared performing surgery within that timeframe, with differences between private and public system. Regarding surgical treatment, 94-98% of femoral neck fractures are treated with an arthroplasty and 98-99% of per-subtrochanteric fractures are treated with internal fixation and osteosynthesis. Osteoporosis treatment is only carried out by 51% of the respondents and with significant variation., Conclusions: This survey shows that there is agreement in surgical practice between specialists treating these patients, but clear differences in preoperative optimization, treatment timeframe, and post fracture medical treatment.

Purpose: The aim of the present study was to assess the first experience with outpatient total hip arthroplasty (THA) in a public health environment in Chile., Methods: Prospective series of the first 69 patients/72 hips. Surgery was performed in a public university-affiliated hospital. The patients were 64 (31-84) years old and healthy (ASA I-II) candidates for a primary hip arthroplasty., Results: The outpatient track had 52.2% of arthroplasty candidates included and 94.4% (68/72 hips) were successfully discharged the same day. There were no emergency room visits during the first week after surgery. Two patients had single dislocation episodes, one requiring stem revision. There was one deep vein thrombosis. There were no other complications. All the patients reported to be satisfied with the outpatient track., Interpretation: An outpatient track can be developed in a safe manner in this healthcare setting and population. This track of care was well accepted by the patients.

The number of osteoporotic fractures is increasing along with population aging. Most patients with these type of fractures are older than 65 years, with multiple chronic conditions and different degrees of disability. Hip fracture is the most relevant osteoporotic fracture due to its frequency, costs, severity and complications. Multidisciplinary management is of the utmost importance to obtain good therapeutic results. We herein review the management of this fracture. Orthogeriatric joint management should be incorporated in fragility fracture treatment. We contribute with general recommendations for the perioperative management, which can be homologated for the management of older patients with other type of fragility fractures.

Background: Surgical dislocation of the hip remains an important alternative in hip preservation surgery, especially when a dynamic access to the hip is needed and arthroscopy is not a suitable option. We describe a novel technique for operative dislocation of the hip without trochanteric osteotomy and the clinical results of our patients., Methods: Surgical dislocation of the hip without trochanteric osteotomy was done through a modified lateral approach in all of the cases. A review of demographic, clinical, and radiological data was done in all of the patients operated with this technique between 2010 and 2015. Complications, walking aids, weight-bearing status, and modified Harris Hip Score (mHHS) were also recorded., Results: Six surgical dislocations of the hip were carried out. Indications were tumor resection in five and bulletectomy in one hip. There were two women (four hips) and two men. Mean age was 19 ± 3.8 years. Median follow-up was 2.5 years (range 2-4.5 years). Median mHHS was 92 (90-96). There were no intraoperative nor postoperative complications., Conclusions: Surgical dislocation of the hip without trochanteric osteotomy through a modified lateral approach appears to be a safe, simpler, and effective alternative.

Introduction: It has been postulated that the complex patterns of spinal injuries have prevented adequate agreement using thoraco-lumbar spinal injuries (TLSI) classifications; however, limb fracture classifications have also shown variable agreements. This study compared agreement using two TLSI classifications with agreement using two classifications of fractures of the trochanteric area of the proximal femur (FTAPF)., Material and Methods: Six evaluators classified the radiographs and computed tomography scans of 70 patients with acute TLSI using the Denis and the new AO Spine thoraco-lumbar injury classifications. Additionally, six evaluators classified the radiographs of 70 patients with FTAPF using the Tronzo and the AO schemes. Six weeks later, all cases were presented in a random sequence for repeat assessment. The Kappa coefficient (κ) was used to determine agreement., Results: Inter-observer agreement: For TLSI, using the AOSpine classification, the mean κ was 0.62 (0.57-0.66) considering fracture types, and 0.55 (0.52-0.57) considering sub-types; using the Denis classification, κ was 0.62 (0.59-0.65). For FTAPF, with the AO scheme, the mean κ was 0.58 (0.54-0.63) considering fracture types and 0.31 (0.28-0.33) considering sub-types; for the Tronzo classification, κ was 0.54 (0.50-0.57). Intra-observer agreement: For TLSI, using the AOSpine scheme, the mean κ was 0.77 (0.72-0.83) considering fracture types, and 0.71 (0.67-0.76) considering sub-types; for the Denis classification, κ was 0.76 (0.71-0.81). For FTAPF, with the AO scheme, the mean κ was 0.75 (0.69-0.81) considering fracture types and 0.45 (0.39-0.51) considering sub-types; for the Tronzo classification, κ was 0.64 (0.58-0.70)., Conclusion: Using the main types of AO classifications, inter- and intra-observer agreement of TLSI were comparable to agreement evaluating FTAPF; including sub-types, inter- and intra-observer agreement evaluating TLSI were significantly better than assessing FTAPF. Inter- and intra-observer agreements using the Denis classification were also significantly better than agreement using the Tronzo scheme., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: Vitamin D deficiency is a common condition affecting 40-100% of geriatric population., Aim: To determine the prevalence of vitamin D insufficiency and deficiency in geriatric population surgically treated for hip fracture., Patients and Methods: Analysis of a database of patients aged over 60 years operated for a low energy hip fracture in a three years period. Vitamin D was measured in identified patients, using a blood sample obtained on admission to the hospital. A logistic regression was carried out to evaluate age, gender, morbidity index and season as predictors of vitamin D deficiency., Results: Two hundred and twenty-eight patients aged 84 ± 7 years (82% females), were included in the analysis. One hundred eighty-three patients (80%) presented vitamin D levels below 20 ng/dl (deficiency) and 39 patients (18%) presented with levels between 20 and 30 ng/dl (insufficiency), totaling 98% of patients with hypovitaminosis D. Vitamin D deficiency was especially common among patients with higher American Society of Anesthesiologists (ASA) Physical Status Classification System and during winter-spring period. A negative correlation between age and the proportion of subjects with vitamin D deficiency was found. There was no relation between gender and vitamin D levels., Conclusions: Vitamin D deficiency is especially prevalent in older subjects with hip fracture, reaching 98% in the studied population.

Objective: Total hip arthroplasty (THA) is a common and generally safe procedure; however, among the most devastating complications associated with THA is periprosthetic infection (PPI). The origin of bacteria causing PPI is not completely understood. The aims of the present study were to identify bacterial contamination of light handles with up-to-date culture methods and to determine the safety in using these handles in hip arthroplasty surgery., Methods: A total of 36 surgical handles randomly selected from primary hip arthroplasty procedures were screened for bacterial contamination using 2 different culture methods, including 1 with high sensitivity. Two types of controls were used. Cultures were kept for up to 10 days, and retrieved bacteria were identified., Results: Fifty percent of the light handles yielded positive cultures, demonstrating a bacterial presence on surgical light handles during hip arthroplasty. The most frequently identified bacteria were Staphylococcus epidermidis and Staphylococcus aureus., Conclusion: A large number of positive bacterial cultures were found in manipulated light handles during hip replacement surgery, representing a potential contamination source that could eventually lead to infection in hip arthroplasty.

Introduction: We performed an agreement study of the AO and the Tronzo classifications of fractures of the trochanteric area to determine if they allow communication among practitioners with different levels of expertise., Material and Methods: Complete radiographs of 70 patients with trochanteric fractures were classified by nine evaluators (three hip sub-specialists, three orthopaedic surgery residents and three medical interns) using the AO and the Tronzo classifications. After a six-week interval, all cases were presented in a random sequence for repeat evaluation. The Kappa coefficient (k) was used to determine inter- and intra-observer agreement., Results: Inter-observer: considering the main AO fracture types, the agreement was moderate for sub-specialists (k = 0.60 [0.50-0.70]), residents (k = 0.58 [0.48-0.69]) and medical interns (k = 0.56 [0.45-0.69]). Using AO sub-types, all groups achieved fair agreement (sub-specialists: k = 0.31 [0.25-0.38]; residents: k = 0.32 [0.26-0.38]; medical interns: k = 0.30 [0.24-0.36]). For the Tronzo classification, sub-specialists (k = 0.56 [0.48-0.65]) and residents (k = 0.47 [0.39-0.55]) obtained moderate agreement; medical interns reached fair agreement (k = 0.33 [0.25-0.41]). Intra-observer: considering the main AO fracture types, sub-specialists (k = 0.79 [0.69-0.89]), residents (k = 0.71 [0.60-0.81]) and medical interns (k = 0.70 [0.59-0.82]) obtained substantial agreement. Considering AO sub-types, sub-specialists (k = 0.50 [0.45-0.56]) and medical interns (k = 0.54 [0.48-0.69]) achieved moderate agreement; residents (k = 0.39 [0.33-0.45]) achieved fair agreement. Using the Tronzo classification, all groups obtained substantial agreement (sub-specialists: k = 0.66 [0.58-0.74]; residents: k = 0.63 [0.55-0.71]; medical interns: k = 0.68 [0.60-0.76])., Conclusion: The AO classification allows an adequate communication when considering the main fracture types; the agreement within sub-types is not satisfactory. The Tronzo classification does not allow reliable communication between medical professionals., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Study Design: Cross-sectional study., Objective: To determine the prevalence of thoracic scoliosis in patients aged 50 years or older and to investigate the association of adult thoracic scoliosis with age, sex, and thoracic sagittal curve., Summary of Background Data: The prevalence of adult thoracic scoliosis has not been clearly determined. In addition, limited data are available on the correlation of adult thoracic scoliosis to age, sex, and thoracic kyphosis., Methods: We studied 760 patients aged 50 years or older (380 males and 380 females) who were evaluated using standing chest plain radiographs. The thoracic curvatures in the coronal and sagittal planes were measured using the Cobb method. Scoliosis was defined by the presence of a coronal curvature 10° or more. We performed a correlation analysis of the coronal curve with age and sagittal curve; in addition, a linear regression analysis was carried out to evaluate age, sex, and sagittal curve as independent predictors of the coronal Cobb angle of the thoracic spine., Results: The prevalence of thoracic scoliosis was 24.2% (184 cases); 160 patients (21.1%) had curves 10° or more but less than 20°; 20 patients (2.6%) had curves 20° or more but less than 30°; and 4 patients (0.5%) had curves 30° or more. Females exhibited a higher prevalence of scoliosis (28.9%) than did males (19.4%), P < 0.01. The older patients exhibited increased scoliosis, but no differences were observed in thoracic kyphosis with increasing scoliosis. Age and sex were independent predictors of the coronal Cobb angle; however, the sagittal angle was not., Conclusion: We found a 24.2% prevalence of thoracic scoliosis in patients 50 years or older; most curves were less than 20°. Thoracic scoliosis was more common in females and in older patients., Level of Evidence: 3.