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Background: Dalbavancin (DAL) off-label use for treating bone and joint infections has increased especially as long-term intravenous access is not needed. Little is known about the effectiveness and safety of its use. Methods: This retrospective, single-center, descriptive study included adults treated with DAL for bone or joint infections over a 4-year period (2019-2023). Patient demographics, infection type and location, pre-DAL antibiotic and surgical treatments, indication for DAL, and clinical outcomes were collected. Risk factor analysis for 1-year infection recurrence was performed. Results: There were 58 patient encounters of bone and/or joint infections treated with DAL. The majority of patients were treated for osteomyelitis (81.0%) followed by native (8.6%) and peri-prosthetic (10.4%) joint infection. Fifty (86.2%) patients underwent surgical intervention, and 17 (68%) of the 25 patients with infected hardware had full hardware removal. The most common pathogen identified was Staphylococcus aureus (41; 70.7%), with methicillin-resistant Staphylococcus aureus isolated in 23 (40.0%) cases. Ten (17.2%) patients had recurrence within 1 year. Hardware removal was found to significantly decrease the risk of infection recurrence (P = .026). None of the peri-prosthetic joint infection patients had infection recurrence within 1 year. Conclusions: Our findings support DAL as an effective treatment for bone and joint infection when combined with surgical debridement and hardware removal. Failure to remove infected hardware significantly increased the risk of infection recurrence within 1 year. Randomized controlled trials are needed to further support DAL as a novel treatment for orthopedic infections.

Introduction 1 mm cerclage cables have been introduced that can be placed under plates and hold reduction of periprosthetic femur fractures (PPFFx) around total hip arthroplasty (THA). Their utilization remains controversial due to the risk of nonunion secondary to periosteal stripping associated for their application. We compared surgical outcomes in patients with THA PPFFx treated with open reduction internal fixation (ORIF) and cables vs patients with PPFFx treated with ORIF without cables. We hypothesized that cable use would decrease hardware failure and nonunion rates. Materials & Methods We retrospectively reviewed 42 cases of PPFFx around THA performed from 2015 to 2021. Twenty-three PPFFx were treated with plate and 1 mm cerclage cables, and 19 PPFFx were treated with plate without cables. Primary surgical outcomes included hardware failure, nonunion, reoperation, and time to radiographic union. Results There was no significant difference in nonunion rates: 9% in the cerclage cable group vs 16% in the plate-only group ( P = .64). The average time to union was 6.0 months among 17 observed unions in the cerclage cable group, vs 8.0 months among 15 observed unions in the plate-only group, but this failed to reach significance ( P = .12). There was no statistical difference in overall complication rates (13% cerclage vs 16% plate) requiring reoperation ( P = 1.0). Discussion & Conclusion The utilization of 1 mm cerclage cables to hold reduction of PPFFx provides an easy method to hold fixation with a low overall complication rate and no significant differences in nonunion rate or time to union when compared to cases performed without cables.

Background: Periprosthetic femur fractures (PPFFs) following total hip arthroplasty (THA) have increased in the past decade as the demand for primary surgery continues to grow. Although there is now more evidence to describe the treatment of Vancouver B fractures, there is still limited knowledge regarding factors that cause surgeons to perform either an open reduction and internal fixation (ORIF) or revision THA (rTHA). The purpose of this study was to determine what type of surgeons treat Vancouver B PPFFs at 11 major academic institutions and if there are trends in treatment decision-making regarding the use of ORIF or rTHA based on surgical training or patient factors. Methods: This multicenter retrospective study evaluated patients surgically treated for Vancouver B PPFF after THA between 2014 and 2019. Patients from 11 academic centers located in the United States were included in this study. Surgical outcomes and patient demographics were evaluated based on surgeon training, surgical treatment type, and institution. Results: Presence of Vancouver B2 (odds ratio [OR]: 0.02, P < .001) or B3 (OR: 0.04, P < .001) fractures were independent risk factors for treatment with rTHA. Treatment by a trauma (OR: 12.49, P < .001) or other-specified surgeon (OR: 13.63, P < .001) were independent risk factors for ORIF repair of Vancouver B fractures. There were no differences in outcomes based on surgeon subspecialty training. Conclusions: This study showed the trends in surgeons who surgically manage Vancouver B fractures at 11 major academic institutions and highlighted that regardless of surgical training or surgical treatment type, postoperative outcomes following management of PPFF were similar.

Background: Semipermanent functional spacers are now utilized for prosthetic joint infection in an attempt to avoid another surgery with 2-stage treatment. This study evaluates the results of metal-on-polyethylene articulating spacers for the treatment of chronic native septic knee arthritis. Methods: This is a retrospective review of 18 patients treated with metal-on-polyethylene articulating antibiotic spacers constructed with all-polyethylene tibial components or with polyethylene inserts (PIs) with Steinmann pins or screws for chronic native knee infection. Demographic information, spacer construct type, prior knee surgery, complications, infecting organisms, infection eradication, and functional results were analyzed. Results: Of 18, 8 (44%) spacers were all-polyethylene tibial components and 10 (56%) were PI. Of 18 patients, 5 (28%) experienced spacer complications. Of 18 patients, 12 (67%) underwent a second reimplantation surgery (mean 106 days), while 6 (33%) retained their spacer (average duration 425 days). The PI group performed better in Knee Injury and Osteoarthritis Outcome score for Joint Replacement according to minimum clinically important difference and patient acceptable symptom state (PASS) criteria. The overall reimplantation group achieved Knee Injury and Osteoarthritis Outcome score for Joint Replacement PASS criteria and minimum clinically important difference criteria, while the maintained articulating spacer group did not achieve PASS criteria; however, they did reach minimum clinically important difference. Conclusions: Functional articulating spacers are a viable treatment for chronic, native knee septic arthritis. The PI patient group had a greater improvement in Knee Injury and Osteoarthritis Outcome score for Joint Replacement scores and had no significant difference in reimplantation rate as the all-polyethylene tibial components patient group. Both planned 2-stage reimplantation and longer-term spacer retention show promising results for this difficult clinical problem.

Background: There has been a shift toward same-day discharge (SDD) in total joint arthroplasty (TJA) in recent years. Our clinical standard had been next-day discharge, but the COVID pandemic led to a hospital bed shortage, causing us to shift to SDD directly from the Post-Anesthesia Care Unit (PACU). The aim of our project was to investigate if the SDD protocol was successful and if it changed complications or 90-day readmission rates. Our secondary aim was to investigate if the protocol created disparities in patient selection. Methods: A retrospective review compared the first 100 patients intended to discharge from PACU to the 100 patients prior to the SDD protocol undergoing elective primary TJA procedures at our academic institution from September 1, 2020, to March 23, 2021. The SDD protocol started on November 19, 2020. Results: During this SDD period, 98% (98/100) of patients were successfully discharged from the PACU. The 90-day readmission rate changed from 0% to 2% (P = .4975), and the overall complication rate changed from 2% to 5% (P = .4448). Most complications were manipulation under anesthesia to improve range of motion. Manipulations under anesthesia changed from 1% to 4% (P = .3687). Conclusions: The transition to same SDD in TJA at our academic institution was successfully implemented without markedly increasing complications, readmissions, or changing patient selection. The COVID-19 pandemic likely influenced the recovery of patients before and after the protocol. Future studies are needed to validate this data during the post-COVID era.

Background: Robotic total knee arthroplasty (R-TKA) utilization and marketing continue to rise. We examined the marketing on surgeon websites regarding R-TKA benefits and sought to determine if the claims were supported by existing literature. Methods: A Google search identified 10 physician websites from each of the 5 largest U.S. markets by population with the term “robotic total knee arthroplasty city, state.” Claims on websites about R-TKA were categorized. Literature from 2012-2022 was reviewed for data “for” or “against” each claim. Level of evidence for each publication was collected. Results: Fifty websites were captured that included 59 surgeons. A specific R-TKA platform was mentioned on 68% of websites. Website claims about robotics were placed into 8 major categories. Literature review supported the claims of more precise/accurate, reduced injury to tissue, and less pain with more literature “for” than “against” the claims. Conclusions: Claims made on physician websites regarding the benefits of R-TKA are variable and not definitively supported by existing literature. Most available data can be categorized into levels of evidence III, IV, and V. There is a paucity of level I evidence to support the various marketing statements. Physicians should be cognizant of both the claims made on their websites and the literature that could be used to support or refute those specific claims.

Introduction A negative correlation exists between functional outcomes and leg length discrepancy (LLD) following hip fracture repair. We have assessed the effects of LLD following hip fracture repair in elderly patients on 3-meter walking time, standing time, activities of daily living (ADL), and instrumental activities of daily living (IADL). Methods One hundred sixty-nine patients enrolled in the STRIDE trial were identified with femoral neck, intertrochanteric, and subtrochanteric fractures that were treated with partial hip replacement, total hip replacement, cannulated screws, or intramedullary nail. Baseline patient characteristics recorded included age, sex, body mass index Charlson comorbidity index (CCI) score. ADL, IADL, grip strength, sit-to-stand time, 3-meter walking time and return to ambulation status were measured at 1 year after surgery. LLD was measured on final follow-up radiographs by either the sliding screw telescoping distance or the difference from a trans-ischial line to the lesser trochanters, and was analyzed as a continuous variable using regression analysis. Results Eighty eight patients (52%) had LLD 10 mm. Age, sex, BMI, Charlson score, and ambulation status had no significant impact on LLD occurrence. Type of procedure and fracture type did not correlate with severity of LLD. Having a larger LLD was not found to have a significant impact on post-operative ADL ( P = .60), IADL ( P = .08), sit-to-stand time ( P = .90), grip strength ( P = .14) and return to former ambulation status ( P = .60), but did have a statistically significant impact on 3-meter walking time ( P = .006). Discussion LLD after hip fracture was associated with reduced gait speed but did not affect many parameters associated with recovery. Continued efforts to restore leg length after hip fracture repair are likely to be beneficial.

Background: Current literature does not provide conclusive evidence on whether routine pathologic examination of femoral heads from total hip arthroplasty is indicated or cost-effective. As a result, there is substantial variation in opinion among surgeons related to this issue. Our study aim was to determine factors that impact surgeon propensity to order pathologic examination of femoral heads. Methods: A 12-question survey was created to evaluate surgeon practices, indications, and patient care implications surrounding routine pathologic examination of femoral heads. The email survey was distributed to all members of the American Association of Hip and Knee Surgeons (n = 2598). Results: There were 572 survey respondents. Out of all respondents, 28.4% always send femoral heads to pathology, and 27.6% reported an institutional requirement to do so. Of the 572 surgeons, 73.6% report femoral head pathology has never resulted in a change in patient disease course. Factors that increase the likelihood of surgeons ordering femoral head pathologic examination include institutional requirements, medicolegal concern, and prior experience with femoral head pathologic examination changing patients' disease course (P < .001). Cost concern decreases the likelihood of surgeons ordering femoral head pathologic examination (P = .0012). Conclusions: A minority of surgeons routinely send femoral heads from total hip arthroplasty for pathologic examination, mostly because of institutional requirement. The majority of surgeons feel that femoral head pathologic examination never changes patient management, although others have infrequently detected malignancy and infection. Institutional policy, concern for litigation, and prior experience with discordant pathologic diagnoses increase femoral head pathologic examinations, while cost concern decreases them.

Articulating hip spacers for periprosthetic joint infection (PJI) offer numerous advantages over static spacers such as improved patient mobilization, hip functionality, and soft tissue tension. Our study aimed to determine complication rates of a functional articulating spacer using a constrained liner to determine the role of acetabular cementation mantle and bone loss on the need for second-stage surgery. A retrospective review of 103 patients was performed and demographic information, spacer components and longevity, spacer-related complications, reinfection rates, and grade of bone loss and acetabular cement mantle quality were determined. There was no significant difference in spacer-related complications or reinfection rate between PJI and native hip infections. 33 of 103 patients (32.0%) elected to retain their spacers. Between patients who retained their initial spacer and those who underwent reimplantation surgery, there was not a significant difference in cement mantle grade (p = 0.52) or degree of bone loss (p = 0.78). Functional articulating antibiotic spacers with cemented constrained acetabular liners demonstrate promising early results in the treatment of periprosthetic and native hip infections. The rate of dislocation events was low. Further efforts to improve cement fixation may help decrease the need for second-stage reimplantation surgery.

Background: Extensor mechanism disruption (EMD) combined with periprosthetic joint infection (PJI) after total knee arthroplasty are life-changing complications. The literature suggests many eventually receive above-knee amputation and lose ambulatory function. An alternative is modular knee fusion (KF), but little is known about its outcomes and biomechanical function. We report early term results on a case series of patients. Methods: A retrospective review was conducted of patients who underwent 2-stage reconstruction with modular KF for combined EMD and PJI. Patient-reported outcomes at 1 year after arthrodesis and complications of surgery were recorded. Biomechanical analysis was conducted on 6 patients >1 year after surgery to measure gait speed and balance. Results: Fifteen patients received a modular KF. At the most recent follow-up visit (average 25.7 months), 12 patients had their modular KFs in place and were ambulatory while 2 had died. Six patients used a walker; 4, a cane; and 2, unassisted. Gait analysis of 6 of these patients showed variation in patterns and speed. Balance was better than historical controls treated with above-knee amputation. Average Knee Injury and Osteoarthritis Outcome Score Junior was 76 ± 11. Conclusion: Modular KF for EMD and PJI can result in successful outcomes in terms of preventing additional operations and maintaining ambulation. While speed is variable, physical testing shows this method for limb salvage may allow patients to ambulate with a gait aid although further studies are needed to evaluate midterm and long-term results.

Isolated patellar resurfacing served as an early treatment for patellofemoral arthritis but was abandoned because of erosion of the native femoral trochlear groove over time. We present the case of a large native tibial osteolytic lesion 20 years after isolated patellar resurfacing with a cemented polyethylene component. The patient had severe tricompartmental arthritic changes. The patellar component was very worn, and the resultant particle debris produced a large cavitary lesion in the proximal tibia. Osteolysis is a rare complication in patellofemoral arthroplasty, and, to our knowledge, this is the first reported case of native tibial osteolysis after isolated patellar resurfacing. The patient was treated with initial curettage and bone grafting of the lesion followed by total knee arthroplasty with a tibial cone and stemmed tibial fixation.

Background: There is considerable disparity in institutional practices surrounding routine pathologic examination of femoral heads removed during total hip arthroplasty (THA). Multiple groups have studied the merits of routine femoral head pathology in THA, without clear consensus. We sought to further investigate the existing evidence on routine pathologic examination of femoral heads retrieved during THA to determine if this practice provides additional clinical value and is cost-effective. Material and methods: To conduct a systematic review of the literature, a medical librarian was consulted to develop and perform comprehensive searches in PubMed (1809-present), Embase (embase.com 1974-present), CINAHL (EBSCO, 1937-present), and the Cochrane Central Register of Controlled Trials (Wiley). Final searches resulted in 727 references. Through multiple reviewer screenings and assessments of eligible full-text articles, we included 14 articles for review. Results: Our systematic review yielded pathologic examination results from 17,388 femoral head specimens collected during THA. In 0.85% of cases, the pathologic diagnosis differed in a meaningful way from the preoperative clinical diagnosis. Routine pathology changed patient management in approximately 0.0058% of cases. The average cost for pathologic examination of each specimen was $126.38. Conclusion: Routine pathologic examination of femoral heads retrieved during THA has limited impact on patient management. With an estimated 500,000 THAs performed in 2019, the economic feasibility of routine femoral head pathology is limited at an annual cost of up to $63,000,000 and cost per quality-adjusted life-year approaching infinity. However, surgeon discretion on a patient-specific or practice-specific basis should be used to make the final determination on the need for femoral head pathology.

Patients with malignancy are often profoundly immunocompromised due to chemotherapy, placing them at potential increased risk for periprosthetic joint infection (PJI). However, there is little information regarding PJI management in these patients. We describe 4 patients with a history of primary total knee arthroplasty followed by diagnosis of multiple myeloma or Waldenström macroglobulinemia who received chemotherapy within 4 months prior to PJI. The Musculoskeletal Infection Society major and minor criteria and either debridement, antibiotics, and implant retention or a 2-stage approach appear to be effective for acute or chronic PJI, respectively. We recommend an anticoagulant be administered concomitantly with antineoplastics that significantly increase deep vein thrombosis risk, and we recommend long-term oral suppressive antibiotics postoperatively, especially if chemotherapy will be resumed. Additional studies are needed to investigate risks and benefits of PJI prophylaxis during chemotherapy and long-term suppressive antibiotics after PJI treatment.

Introduction Corneal abrasion (CA) is the most common ocular complication in patients undergoing nonocular surgery. Corneal abrasions can be caused by a variety of mechanisms, the most common being drying of the cornea due to reduced tear secretions, loss of eyelid reflex, and the loss of pain recognition during surgery. Though CA heals well with eye lubricants, it can result in significant ocular pain and some cases may go on to develop ocular complications. With the current switch to outpatient total joint replacement, CA could potentially lead to discharge delays. Materials and Methods We examined the results of a quality improvement project to reduce CA during general anesthesia to determine the rates of CA during hip and knee total joint replacement. We compared rates of CA for 6 months before and 6 months after the intervention. Results A total of 670 hip and knee arthroplasty procedures were performed during this period. Two events of CA occurred, one occurred before and one after the intervention to decrease eye injuries. Both incidences occurred during total hip arthroplasty (THA) procedures with the patient in the lateral decubitus position and recovered without long-term deficit. Discussion Surgeons and anesthesiologists alike should be cognizant of this avoidable complication and take precaution to protect the eyes during surgery, especially during THA when the patient is placed in the lateral decubitus position. Conclusion Corneal abrasion during total joint arthroplasty is a rare complication and is infrequently addressed in the literature. CA is mostly self-limiting, however, but may lead to patient dissatisfaction and to delays if same-day discharge is attempted. Preventative measures and attentive care may help reduce the incidence of CA in patients undergoing total joint arthroplasty. The lateral decubitus position and longer surgeries times are risk factors for CA.

Introduction The Bundled Payment for Care Improvement (BPCI) for hip and femur fractures is an effort to increase care quality and coordination at a lower cost. The bundle includes all patients undergoing an operative fixation of a hip or femur fracture (diagnosis-related group codes 480-482). This study aims to investigate variance in the hospital cost and readmission rates for patients within the bundle. Materials and Methods The study is a retrospective analysis of patients ≥65 years old billed for a diagnosis-related groups 480-482 in 2016 in the National Readmission Database. Cost of admission and length of stay were compared between patients who were or were not readmitted. Regression analysis was used to determine the effects of the primary procedure code and anatomical location of the femur fracture on costs, length of stay, and readmission rates. Results Patients that were readmitted within 90 days of surgery had an increased cost on initial admission ($18,427 vs $16,844, P < .0001), and an increased length of stay (6.24 vs 5.42, P < .0001). When stratified by procedure, patients varied in readmission rates (20.7% vs 19.6% vs 21.8%), initial cost, and length of stay (LOS). Stratification by anatomical location also led to variation in readmission rates (20.7% vs 18.3% vs 20.6%), initial cost, and LOS. Conclusion The hip and femur fractures bundle includes a great number of procedures with variance in cost, readmission, and length of stay. This amount of variation may make standardization difficult and may put the hospital at potential financial risk.

Introduction Public health achievements throughout the last century have resulted in a steady increase in life expectancy. An emergent subset has distinguished themselves, living well beyond the ninth decade by avoiding or delaying the onset of most age-related diseases, including bone diseases and fractures. In this study, we evaluated the bone health of the oldest community-dwelling individuals living in rural Arkansas. Methods 299 patients aged ≥90 years were retrospectively reviewed for recorded fractures within 12 years prior to the investigation period. Records were also examined for medications and test results pertinent to bone health, including thyroid stimulating hormone, vitamin D levels, hematocrit, hemoglobin, body mass index, and bone densitometric values. Results 68 patients (23%) had at least one fracture documented, and 15 had >1 fracture. 40% of patients with fractures had osteoporosis and 28% had osteopenia, respectively. 232 patients (78%) had no documented fractures, and of these, only 18% had osteoporosis and 16% had osteopenia. No significant clinical markers were found among the very old to explain the relatively low occurrence of fractures. Conclusions Patients over 90 years of age had an overall low prevalence of fractures and relative preservation of bone health, suggesting a preserved bone molecular profile in these individuals. Epigenetic factors and activity levels might also have favorably affected bone health. The low percentage of osteoporosis and fractures likely reduced the morbidity and mortality in this population, potentially contributing to their overall longevity.

Introduction: Periprosthetic femur fractures (PPFX) are complications of both total hip and knee arthroplasty and may be treated with open reduction and internal fixation (ORIF) or revision arthroplasty. Differences in treatment and fracture location may be related to patient demographics and lead to differences in cost. Our study examined the effects of demographics and treatment of knee and hip PPFXs on length of stay (LOS) and cost. Methods: Of all, 932 patients were identified with hip or knee PPFXs in the National Inpatient Sample from January 2013 to September 2015. Age, gender, race, mortality, comorbidity level, LOS, total cost, procedure type, geographic region, and hospital type were recorded. A generalized linear regression model was conducted to analyze the effect of fracture type on LOS and cost. Results: Differences in gender (66% vs 83.7% female, P < .01), comorbidities (fewer in hips, P < .01), and costs (US$30 979 vs US$27 944, P < .01) were found between the hip and knee groups. Knees had significantly higher rates of ORIF treatment (80.7% vs 39.1%) and lower rates of revision arthroplasties (19.3% vs 60.9%) than hip PPFXs ( P < .01). Within both groups, patients with more comorbidities, revision surgery, and blood transfusions were more likely to have a longer LOS and higher cost. Conclusion: Periprosthetic femur fractures patients are not homogenous and treatment varies between hip and knee locations. For knee patients, those treated with ORIF were younger, with fewer comorbidities than those treated with revision. Conversely, hip patients treated with ORIF were older, with more comorbidities than those treated with revision. Hips had higher costs than knees, and cost correlated with revision arthroplasty and more comorbidities. In both hip and knee groups, longer LOS was associated with more comorbidities and being treated in urban teaching hospitals. Total cost had the strongest associations with revision procedures as well as number of comorbidities and blood product use.

Introduction: With the increase in knee and hip implants, these periprosthetic fractures will become more common especially as the population ages. Open periprosthetic fractures are rare and severe injuries and are more likely to be seen in high-energy injuries. They present challenges to the treating physician due to soft tissue damage, contamination of the existing implants, and the effects of polytrauma in the geriatric patient. Methods: Case review report and review of literature . Results A 72-year-old woman was involved in a motor vehicle collision with multiple injuries including an open periprosthetic tibia and femur fracture. This was treated with initial washout and removal of loose tibial component with placement of a cement spacer. The knee was treated with staged revision using a protocol like that used after prosthetic joint infection. After complete soft tissue healing, the patient underwent successful revision with a megaprosthesis. The literature on open periprosthetic fractures is reviewed. Discussion and Conclusion: Open periprosthetic fractures present multiple challenges to the orthopedic surgeon. In the presences of poly trauma and soft tissue injury, we present an approach using staged surgery like that used for prosthetic joint infection.

Background: The majority of patients require postacute care (PAC) after a hip fracture. Despite its importance, there is no established consensus regarding the standards of care provided to hip fracture patients in PAC facilities. Methodology: A writing group was created by professionals from the International Geriatric Fracture Society (IGFS) with representation from other organizations. The focus of the statements included in this article is toward PAC providers located in nursing facilities. Contributions were integrated in a single document that underwent several reviews by each author and then underwent a final review by the lead and senior authors. After this process was completed, the document was appraised by reviewers from IGFS. Results/Conclusion: A total of 15 statements were crafted. These statements summarize the best available evidence and is intended to help PAC facilities managing older adults with hip fractures more efficiently, aiming toward overall better outcomes in the areas of function, quality of life, and with less complications that could interfere with their optimal recovery.

Introduction: Management of periprosthetic infection in total hip arthroplasties is challenging, especially when there is severe loss of proximal femoral bone stock. When a 2-stage approach is used, either a static or an articulating spacer may be considered. Static spacers leave the patient with a flail leg, which can be very difficult with massive bone loss. The purpose of this study is to report a novel technique for articulating antibiotic spacers and report our results. Materials and Methods: We describe a technique for an articulating hip spacer in the setting of a large amount of proximal femoral bone loss using a locked intramedullary nail, modular femoral body, and an all-polyethylene constrained acetabular component. This technique allowed for mobilization of the patient without a flail leg. Four patients underwent 2-stage reconstruction, and the case series is reported here. Results: No complications occurred due to the spacer, and in all cases, a second reconstruction was later carried out after treatment with intravenous antibiotics. Three of 4 patients did well after 2-stage reconstruction, with 1 patient ultimately requiring an amputation. Discussion: We feel this technique improves upon previously reported large spacers due to the stability and maintenance of leg length. Conclusion: This technique offers a modular solution to address massive bone loss of the proximal femur in the face of periprosthetic joint infection.

Introduction: Older patients with hip fracture have a 20% to 30% mortality rate in the year after surgery. Nonoperative care has higher 1-year mortality rates and is generally only pursued in those with an extraordinarily high surgical risk. As the population ages, more patients with hip fracture may fall into this category. The orthopedic surgeon is typically the main consultant responsible for deciding between surgery and conservative management, and the reasoning behind one decision over the other is often poorly understood. We undertook a review to determine decision-making tools for surgery in high-risk patients with hip fracture. Materials and Methods: A review was conducted using PubMed to determine articles published using the terms palliative care, conservative care, nonoperative, hip fracture, orthopedic procedures, fracture fixation, and surgery. Our search resulted in 13 articles to review. These were further screened to determine tools for use in surgical decision-making. Results: Several potential decision-making tools were found in our search. The potential tools to identify patients who would benefit from nonoperative treatment included the Palliative Performance Scale for severe dementia, the Lawton Instrumental Activities of Daily Living and Katz Activities of Daily Living scales for prefracture immobility, a combination of clinical signs and laboratory tests to determine risk of imminent death, and the Charlson Comorbidity Score for additional serious comorbidities. No tools have been prospectively tested in a clinical setting. Discussion: Evaluation of each patient using a variety of decision making tools should help the orthopedic surgeon determine which patients would be better suited to non-operative management. After determining the benefit of non-operative care, they must effectively allow the fracture to heal while ameliorating pain. Palliative care physicians can fulfill this role by providing support and symptom relief. Conclusions: Surgical decision-making for hip fracture repair in the elderly patients is not straight forward. Several tools may be helpful to the surgeon in determining who may be better suited for nonoperative care or a palliative care referral. Prospective data do not exist in these decision-making tools.

Objectives: Bone lesions from multiple myeloma may lead to pathological fracture of the proximal femur, requiring either fixation or arthroplasty. Little is known about the impact of multiple myeloma on hip fracture care. We investigated whether the patients with multiple myeloma undergoing surgical treatment of hip fractures would be at increased risk for adverse outcomes versus patients who sustain a hip fracture without multiple myeloma. Methods: Using discharge records from the Nationwide Inpatient Sample (2002-2011), we identified 2 440 513 patients older than 50 years of age with surgically treated hip fractures. Of which, 4011 (0.2%) were found to have multiple myeloma. We compared perioperative outcomes between the patients with multiple myeloma and the nonmultiple myeloma patients using multivariable logistic regression modeling. Results: Patients with multiple myeloma were more likely to have several postoperative complications, such as in-hospital pneumonia (odds ratio [OR]: 1.31, 95% confidence interval [CI]: 1.14-1.51), sepsis (OR: 1.72, 95% CI: 1.32-2.25), surgical site infection (OR: 1.66, 95% CI: 1.38-2.00), and acute renal failure (OR: 1.28, 95% CI: 1.14-1.43). We found that myeloma was not associated with increased inpatient mortality, myocardial infarction, respiratory failure, thromboembolic events, or pulmonary embolism. Conclusion: Patients with multiple myeloma are at increased risk for immediate postoperative complications following surgical treatment of hip fractures including in-hospital pneumonia, surgical site infection, and acute renal failure but not hospital mortality, when compared to hip fracture patients without multiple myeloma. Perioperative management of hip fractures in patients with myeloma may be optimized by increased awareness of these risks in this subset of patients.

Over the past 4 decades, much has been learned about the pathophysiology and treatment of osteoporosis, the prevention of fragility fractures, and the perioperative management of patients who have these debilitating injuries. However, the volume of published literature on this topic is staggering and far too voluminous for any clinician to review and synthesize by him or herself. This manuscript thoroughly summarizes the latest research on fragility fractures and provides the reader with valuable strategies to optimize the prevention and management of these devastating injuries. The information contained in this article will prove invaluable to any health care provider or health system administrator who is involved in the prevention and management of fragility hip fractures. As providers begin to gain a better understanding of the principles espoused in this article, it is our hope that they will be able to use this information to optimize the care they provide for elderly patients who are at risk of or who have osteoporotic fractures.

Geriatric hip fractures are a challenging clinical problem throughout the world. Hip fracture services have been shown to shorten time to surgery, decrease the cost of admissions, and improve the outcomes. We instituted a geriatric hip fracture program for comanagement of these injuries by orthopedic and internal medicine teams at our hospital in India. From January 2010 till December 2011, 119 patients with a femoral neck fracture were treated with cemented modular hemiarthroplasty under this program using a cost-effective Indian implant. The cohort included 63 males and 56 females with a mean age of 70.7 years (range 55-98 years). Hypertension (n = 42) and diabetes mellitus (n = 29) were the most common comorbidities. The follow-up period ranged from 12 to 37 months with an average of 24 months. The surgery was performed within 24 hours of admission in 60.5% (n = 72) patients. The use of antiplatelet drugs was the most common reason for delay of surgery. The mean length of hospital stay was 10.4 days (range 3-24 days) with 77% (n = 92) of patients discharged within 1 week of admission. On follow-up, good to excellent Harris hip scores were seen in 88% of patients with 76% of patients returning to the preinjury ambulatory status. The mortality rate was 6% at 6 months follow-up and 10.9% at 2 years. Our study shows that a hip fracture program can be instituted in India. The program helped us in achieving the goal of early surgery, mobilization, and discharge from hospital with decreased mortality.

Background and Purpose: Pain after hip fracture repair is related to worse functional outcomes and higher fracture care costs than that for patients with no or less pain. However, to our knowledge, few studies have examined the roles of hip fracture type or surgical procedure as factors influencing postoperative pain or opioid analgesic requirements. Our goal was to determine whether the type of hip fracture or hip fracture repair affects postoperative pain or opioid analgesic requirements in the elderly patient. Methods: We conducted a retrospective review of 231 patients ≥65 years old admitted to a hip fracture center for surgical repair. Fracture patterns were classified into femoral neck (FN) versus intertrochanteric (IT), stable versus unstable, and type of surgical repair. Demographic and intraoperative variables, postoperative pain scores, and opioid analgesic use data were collected and analyzed according to the type of hip fracture and type of surgical repair. Results: There were no differences in postoperative pain when comparing FN versus IT fractures, stable versus unstable fractures, or type of surgical repair. Patients with FN fractures had higher analgesic requirements on postoperative days 1, 2, and 3. There was no difference in postoperative analgesic requirements among patients with stable versus unstable fractures or type of surgical repair. Otherwise, there were no differences in postoperative pain or opioid analgesic use based on the surgical repair or fracture type. Overall, patients with hip fracture experienced low levels of pain.

Time to surgery, which includes time in the emergency department (ED), is important for all patients with hip fracture. We hypothesized that patients with hip fracture spend significantly more time in the ED than do patients with the top 5 most common conditions. In addition, we hypothesized that there are patient, physician, and hospital factors that affect the length of time spent in the ED. We retrospectively reviewed our institution’s hip fracture database and identified 147 elderly patients with hip fractures who presented to our ED from December 18, 2005, through April 30, 2009. We reviewed their records for patient, practitioner, and hospital factors of interest associated with ED time and for 6 specified time intervals. Average working, boarding (waiting for an inpatient room), and total times were calculated and compared with respective averages for admitted ED patients with the top 5 most common conditions. Univariate and multivariate analyses were performed before and after adjusting for confounders (significance, P = .05). The mean total ED time (7 hours and 25 minutes) and working time (4 hours and 31 minutes) for patients with hip fracture were similar to the respective overall averages for admitted ED patients. However, the average boarding time for patients with hip fracture was 2 hours 44 minutes, longer than that for other patients admitted through the ED. Factors significantly associated with longer ED times were a history of hypertension, history of atrial fibrillation, the number of computed tomography scans ordered, and the occupancy rate. Admission to the hip fracture service decreased working time but not overall time. Substantial multidisciplinary work among the ED, hospital admission services, and physicians is needed to dramatically decrease the boarding time and thus the overall time to surgery.

Our goal was to determine whether the pullout strength of stripped screw holes in osteoporotic bone could be increased with readily available materials from the operating room. We inserted 3.5-mm stainless steel nonlocking self-tapping cortical screws bicortically into 5 osteoporotic humeri. Each screw was first stripped by rotating it 1 full turn past maximum torque. In the control group, the screw was pulled out using an MTS machine (858; MTS Inc, Eden Prairie, Minnesota). In the treatment groups, the screw was removed, the hole was augmented with 1 of the 3 materials (stainless steel wire, polysorb suture, or polyethylene terephthalate glycol plastic sheet), and the screws were replaced and then pulled out. The effect of material on pullout strength was checked for significance ( P < .05) using a general linearized latent and mixed model (Stata10; StataCorp, College Station, Texas). The mean (95% confidence interval) pullout strength for the unaugmented hole was 138 N (range 88-189), whereas the holes augmented with plastic, suture, or wire had mean pullout strengths of 255 N (range 177-333), 228 N (range 149-308), and 396 N (range 244-548), respectively. Although wire augmentation resulted in pullout strength that was significantly greater than that of the unaugmented screw, it was still below that of the intact construct.

Clostridium difficile infection (CDI) is the most common infectious cause of nosocomial diarrhea in elderly patients, accounting for 15% to 25% of all cases of antibiotic-induced diarrhea in those patients. Virulent forms of this organism have developed, increasing the associated morbidity, mortality, and complication rates. The average patient undergoing total joint arthroplasty is at particular risk of CDI because of advanced age, the use of prophylactic antibiotic coverage in the perioperative period, multiple comorbid conditions, and length of hospital stay. In addition, patients who have had one CDI are at risk of another; the rate of recurrent CDI (RCDI) is 15% to 30%. To review the available information on RCDI, we conducted an extensive literature search, focusing on its epidemiology and the management strategies for its treatment and prevention. We found the management of RCDI is a controversial topic, with as yet no consensus regarding specific treatment guidelines. Several experienced clinicians have published suggested treatment algorithms, but they are based on anecdotal experience. With regard to the prevention of RCDI, the literature is scarce, and currently, the only effective strategies remain judicious use of perioperative antibiotics and appropriate implementation of infection control procedures. There are several vaccination medications that are currently being studied but are not yet ready for clinical use. We agree with the approach to management of RCDI that has been proposed in several articles, that is, on confirmation of a first recurrence of CDI by a stool toxin assay and clinical symptoms, a 14-day course of metronidazole or vancomycin; for a second recurrence, a tapered-pulsed course of vancomycin; and, for 3 or more recurrences, a repeat course of the tapered-pulsed vancomycin and adjunctive Saccharomyces boulardii or cholestyramine.

Periprosthetic fractures of the femur in association with total hip arthroplasty are increasingly common and often difficult to treat. Patients with periprosthetic fractures are typically elderly and frail and have osteoporosis. No clear consensus exists regarding the optimal management strategy because there is limited high-quality research. The Vancouver classification facilitates treatment decisions. In the presence of a stable prosthesis (type-B1 and -C fractures), most authors recommend surgical stabilization of the fracture with plates, strut grafts, or a combination thereof. In up to 20% of apparent Vancouver type-B1 fractures, the femoral stem is loose, which may explain the high failure rates associated with open reduction and internal fixation. Some authors recommend routine opening and dislocation of the hip to perform an intraoperative stem stability test to rule out a loose component. Advances in plating techniques and technology are improving the outcomes for these fractures. For fractures around a loose femoral prosthesis (types B2 and 3), revision using an extensively porous-coated uncemented long stem, with or without additional fracture fixation, appears to offer the most reliable outcome. Cement-in-cement revision using a long-stem prosthesis is feasible in elderly patients with a well-fixed cement mantle. It is essential to treat the osteoporosis to help fracture healing and to prevent further fractures. We provide an overview of the causes, classification, and management of periprosthetic femoral fractures around a total hip arthroplasty based on the current best available evidence.

Our goal was to determine whether there were age-related differences in pain, opiate use, and opiate side effects after total hip or knee arthroplasty in patients 60 years old or older. We hypothesized that there would be no significant differences between age groups in (1) mean pain score, (2) opiate use after adjusting for pain, or (3) opiate side effects after adjusting for opiate use and pain score. We retrospectively reviewed the electronic and paper charts of all patients undergoing total joint replacements at our institution over 3 years who met the following criteria: (1) 60 years old or older, (2) primary single total knee or total hip replacement, and (3) no preoperative dementia. Preoperative, intraoperative, and postoperative course data were collected using a customized data entry process and database. We divided the patients into 2 age groups, those 60 to 79 years old and those 80 years old or older. Using a marginal model with the panel variable of postoperative day, we investigated the associations between age group and pain, age group and pain adjusting for opiate use, and age group and complications (respiratory depression, naloxone usage as a measure of respiratory arrest, delirium, constipation, and urinary retention) adjusting for opiate use (Xtgee, Stata10, Stata Corp. LP, College Station, Texas). Significance was set at P < .05. We found no significant difference in pain scores between groups, but the older group had significantly fewer opiates prescribed yet significantly more side effects, including delirium (odds ratio 4.2), than did the younger group, even after adjusting for opiate dose and pain score.

This case presents a discussion of a 92-year-old man with multiple comorbidities, who presents with a subtrochanteric fracture. His course is complicated by large volume blood loss intraoperatively, requiring intensive care unit (ICU) monitoring postoperatively. His course is also complicated by delirium.

Poor screw purchase because of osteoporosis presents difficulties in ankle fracture fixation. The aim of our study was to determine if cortical thickness, unicortical versus bicortical purchase, and bone mineral density are predictors of inadvertent screw stripping and overtightening. Ten paired cadaver ankles (average donor age, 81.7 years; range, 50-97 years) were used for the study. Computed tomography scanning with phantoms of known density was used to determine the bone density along the distal fibula. A standard small-fragment, 7-hole, one-third tubular plate was applied to the lateral surface of the fibula, with 3 proximal bicortical cortical screws and 2 distal unicortical cancellous screws. A posterior plate, in which all 5 screws were cortical and achieved bicortical purchase, was subsequently applied to the same bones and positioned so that the screw holes did not overlap. A torque sensor was used to measure the torque of each screw during insertion (T i ) and then stripping (T s ). The effect of bone density, screw location, cortical thickness, and unicortical versus bicortical purchase on T i and T s was checked for significance ( P < .05) using a general linearized latent and mixed model. We found that 9% of the screws were inadvertently stripped and 12% were overtightened. Despite 21% of the screws being stripped or being at risk for stripping, we found no significant predictors to warn of impending screw stripping. Additional work is needed to identify clinically useful predictors of screw stripping.

Locking plates are commonly used to treat fractures around a well-fixed femoral component. The optimal construct should provide sufficient fixation while minimizing soft-tissue dissection. The purpose of the current study was to determine whether plate length, working length, or bone mineral density affects survival of locking plate fixation for Vancouver type B1 periprosthetic hip fractures. A transverse osteotomy was created just distal to cemented femoral prostheses in 9 pairs of cadaveric femurs. Fractures were stabilized with long (20-hole) or short (12-hole) locking plates that were secured proximally with cables and screws and distally with screws only. Specimens were then cycled 10 000 times at 2500 N of axial force and 15 Nm of torque to simulate full weightbearing. A motion capture system was used to record fracture displacement during cycling. Failure occurred in 5 long and 3 short plates, with no significant differences found in the number of cycles to failure. For the specimens that survived, there were no significant differences found between long and short plates for displacement or rotation observed at the fracture site. A shorter working length was not associated with increased failure rate. Lower bone mineral density was significantly associated with failure ( P = .02). We concluded that long locked plates do not appear to offer a biomechanical advantage over short locking plates in terms of fixation survival, and that bone mineral density was a better predictor of failure than was the fixation construct type.

It has been suggested that variances in the anatomy of the acetabulum determine the type of hip fracture in elderly patients. Based on this concept, an overly anteverted acetabulum would lead to impingement of the femoral neck against the posterior rim of the acetabulum, causing a femoral neck fracture, whereas with a retroverted acetabulum, external rotation of the hip would be limited by the capsular tissues attached to the trochanteric region, causing a trochanteric fracture. To test the hypothesis that acetabular version predicts hip fracture type in elderly patients, we measured acetabular version using computed tomography scans for 135 patients with hip fracture. Logistic regression analysis was used to check for an association between version angle and fracture type. No significant relationship between acetabular version and fracture type was found. Therefore, we conclude that acetabular version angle does not predict hip fracture type in the elderly, and our data do not support the impingement concept as the mechanism of hip fractures.

The purpose of our study was to biomechanically compare, under cyclic loading conditions, fracture site motion, humeral head collapse, and intra-articular hardware penetration in simulated 3-part osteoporotic proximal humeral fractures stabilized with 1 of 2 locking-plate constructs. We performed fixation on simulated 3-part proximal humeral fractures in 10 pairs of cadaveric osteoporotic humeri with a Hand Innovations S3 Proximal Humerus Plate (S3 plate) or an LCP Proximal Humerus Plate (LCP plate; 1 each for each pair). The specimens were potted, mounted on a materials testing machine, and subjected to 5000 cycles of abduction in the scapular plane, loading through the supraspinatus tendon. Interfragmentary displacement at 2 virtual points (the most medial aspect of the calcar and the most superior aspect of the osteotomy line between the greater tuberosity and humeral head) was measured using an optical tracking system. Humeral head rotation was also measured. We used a generalized linear latent and mixed model to check for an effect of cyclic loading and treatment on the parameters of interest (significance, P < .05). After cyclic loading, the S3 plate humeri showed significantly greater displacement of the greater tuberosity fragment and rotation of the humeral head and a trend (not a significant difference) toward greater displacement at the calcar. No hardware penetration was noted for either repair. Although the S3 plate repairs resulted in significantly more fracture site motion, it is unknown whether the magnitude of the motion is clinically significant.

Femoroplasty, the augmentation of the proximal femur, has been shown in biomechanical studies to increase the energy required to produce a fracture and therefore may reduce the risk of such injuries. The purpose of our study was to test the hypotheses that: (1) 15 mL of cement was sufficient to mechanically augment the proximal femur, (2) there was no difference in augmentation effect between cement placement in the intertrochanteric region and in the femoral neck, and (3) cement placement in the femoral neck would predispose the proximal femur to an intertrochanteric fracture, whereas trochanteric placement would result in subtrochanteric fractures. In each of 18 pairs of osteoporotic human cadaveric femora, 15 mL of polymethylmethacrylate bone cement was injected into the trochanteric or femoral neck region of 1 femur, and the noninjected femur was used as the control. The augmentation effect of femoroplasty was evaluated under simulated fall conditions using a materials testing machine. Multiple linear regressions incorporating random effects were used to check for associations between covariates (bone mineral density, cement location, and treatment) and the parameters of interest (stiffness, yield energy, yield load, ultimate load, and ultimate energy). Significance was set at P < .05. It was found that femoroplasty with 15 mL of cement did not significantly increase stiffness, yield energy, yield load, ultimate load, or ultimate energy relative to paired controls. There were no significant differences in parameters of interest or fracture patterns in specimens augmented in the femoral neck versus the trochanter. It was concluded that 15 mL of cement was not sufficient to augment the proximal femur and that there was no biomechanical advantage to the placement of cement within the femoral neck versus the trochanter.

It is unclear if a decrease in cancellous bone density or cortical bone thickness is related to sacral insufficiency fractures. We hypothesized that reduction in overall bone density leads to local reductions in bone density and cortical thickness in cadaveric sacra that match clinically observed fracture patterns in patients with sacral insufficiency fractures. We used quantitative computed tomography to measure cancellous density and cortical thickness in multiple areas of normal, osteopenic, and osteoporotic sacra. Cancellous bone density was significantly lower in osteoporotic specimens in the central and anterior regions of the sacral ala compared with other regions of these specimens. Cortical thickness decreased uniformly in all regions of osteopenic and osteoporotic specimens. These results support our hypothesis that areas of the sacrum where sacral insufficiency fractures often occur have significantly larger decreases in cancellous bone density; however, they do not support the hypothesis that these areas have local reduction of cortical bone thickness.