Alberto Gregori

Early mortality after surgical fixation of hip fractures in the elderly: AN ANALYSIS OF DATA FROM THE SCOTTISH HIP FRACTURE AUDIT

We investigated the relationship between a number of patient and management variables and mortality after surgery for fracture of the hip. Data relating to 18,817 patients were obtained from the Scottish Hip Fracture Audit database. We divided variables into two categories, depending on whether they were case-mix (age; gender; fracture type; pre-fracture residence; pre-fracture mobility and ASA scores) or management variables (time from fracture to surgery; time from admission to surgery; grade of surgical and anaesthetic staff undertaking the procedure and anaesthetic technique). Multivariate logistic regression analysis showed that all case-mix variables were strongly associated with post-operative mortality, even when controlling for the effects of the remaining variables. Inclusion of the management variables into the case-mix base regression model provided no significant improvement to the model. Patient case-mix variables have the most significant effect on post-operative mortality and unfortunately such variables cannot be modified by pre-operative medical interventions.

Gender differences in epidemiology and outcome after hip fracture: EVIDENCE FROM THE SCOTTISH HIP FRACTURE AUDIT

We report gender differences in the epidemiology and outcome after hip fracture from the Scottish Hip Fracture Audit, with data on admission and at 120 days follow-up from 22 orthopaedic units across the country between 1998 and 2005. Outcome measures included early mortality, length of hospital stay, 120-day residence and mobility. A multivariate logistic regression model compared outcomes between genders. The study comprised 25 649 patients of whom 5674 (22%) were men and 19 975 (78%) were women. The men were in poorer pre-operative health, despite being younger at presentation (mean 77 years (60 to 101) vs 81 years (50 to 106)). Pre-fracture residence and mobility were similar between genders. Multivariate analysis indicated that the men were less likely to return to their home or mobilise independently at the 120-day follow-up. Mortality at 30 and 120 days was higher for men, even after differences in case-mix variables between genders were considered.

Outcome After Surgery for the Treatment of Hip Fracture in the Extremely Elderly

BACKGROUND As a consequence of changes in population demographics, the extremely elderly represent one of the fastest growing groups in Western society. Previous studies have associated advanced age with increased mortality after hip fracture; however, this finding has not been consistent. METHODS The Scottish Hip Fracture Audit is a prospective, national, multicenter study that collects data on patients over the age of fifty years who are admitted to the hospital with a hip fracture. For the present study, we used data collected from twenty-two acute-care orthopaedic units between January 1998 and December 2005. The extremely elderly cohort consisted of 919 individuals with an age of ninety-five years or more. Case-mix variables and outcomes were compared with those for a modal control group of 15,461 individuals who were seventy-five to eighty-nine years of age. Outcome measures included thirty and 120-day mortality rates, the length of the hospital stay, the place of residence, and mobility. A multivariable logistic regression model was used to compare outcomes between groups while controlling for significant case-mix variables. RESULTS The extremely elderly presented with poorer indicators of health status as demonstrated by higher American Society of Anesthesiologists scores. In addition, this group was less likely to be independently mobile and more likely to be in institutional care at the time of the fracture (p < 0.001). Mortality at thirty and 120 days was higher in the extremely elderly even after adjusting for case-mix variables. The extremely elderly also were less likely to return home or to return to previous levels of mobility. CONCLUSIONS Although the extremely elderly exhibited a higher prevalence of prefracture indicators of poor outcome, statistical control for these case-mix variables showed further age-related deterioration in survival and outcomes after surgery for the treatment of a hip fracture.

Doctor, can I drive with this plaster? An evidence based response

The purpose of this study is to assess the effect of the commonly used below elbow plaster casts on driving ability. The position of the Driver and Vehicle Licensing Agency and five motor insurance companies is established. The study aims to help doctors decide whether or not a patient is fit to drive with a plaster cast. Three types of cast were tested using one driver. A score was given for several driving abilities. The right Colles cast was found to have no effect on ability to drive. Scaphoid and Bennetts casts were found to have significant affects on driving ability. The DVLA has no specific guidelines regarding driving with a plaster cast and the position of insurance companies is variable, but will usually depend upon medical advice.

Using navigation intraoperative measurements narrows range of outcomes in TKA

Computer-assisted technology creates a new approach to total knee arthroplasty (TKA). The primary purpose of this technology is to improve component placement and soft tissue balance. We asked whether the use of navigation techniques would lead to a narrow range of implant alignment in both coronal and sagittal planes and throughout the flexion-extension range. Using a prospective consecutive series of 57 navigated TKAs, we assessed intraoperative knee measurements, including alignment, varus-valgus stress angles in extension, and varus-valgus angles from 0° to 90° of flexion comparing postimplant with preimplant. We found fewer outliers with coronal (100% of TKAs within ±2°) and sagittal (0% of TKAs with fixed flexion greater than 5°) alignment, soft tissue balancing (mean varus and valgus stress angles −3.2° and 2.3°; range, −5° to 5°), and mean femorotibial angle over flexion range 0° (−0.2°; range, −1° to 2°), 30° (−0.2°; range, −5° to 4°), 60° (−0.5°; range, −5° to 7°), and 90° (−0.2°; range, −5° to 10°). This technology allows a narrow range of implant placement and soft tissue management in extension. We anticipate improved ultimate patient outcomes with less tissue disruption.Level of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Variation of the Vastus Medialis Obliquus Insertion and its Relevance to Minimally Invasive Total Knee Arthroplasty

The aim of the study was to assess population variation of the vastus medialis obliquus (VMO) insertion to the patella. Sixty-five magnetic resonance imaging studies and 18 cadaver specimens were studied. The VMO insertion was expressed as a percentage of patellar length. In the magnetic resonance imaging cohort, the mean insertion was 51% (range 13-95); 59% (38 of 65) of individuals had an insertion within 40% to 60%, with 25% (16 of 65) being distal to 60%. In the cadaveric study, mean insertion was 52% (range 26-81). Both groups displayed a Gaussian distribution. Laterality and sex had no effect upon the level of insertion. The VMO has a variable and frequently distal insertion that may preclude a true quadriceps-sparing approach during minimally invasive knee arthroplasty.

Epidemiology and outcome after hip fracture in the under 65s—Evidence from the Scottish Hip Fracture Audit

AIM To report the epidemiology and outcomes after hip fractures in the patients under 65 years of age. PATIENTS AND METHODS We performed a prospective, multi-centre observational study using the Scottish Hip Fracture Audit Database. Case-mix, process and outcome data was collected by dedicated coordinators on site at the time of admission, at 120 days after the injury and on any re-operations within 12 months. The study cohort consisted of 1896 individuals aged 50-64 years. Patient variables and outcomes were compared to a control group of 15,461 individuals aged 75-89 years of age. The control group consisted of three modal 5-year age groups centred about a median age of 83 years, equal to the database value, excluding the effects of the extreme elderly who may act as confounders. Outcomes measures included 30- and 120-day mortality, length of hospital stay, place of residence and ambulatory status. A multivariate logistic regression model was used to compare outcome between groups while controlling for significant case-mix variables. RESULTS Patients in the study cohort presented with lower ASA scores and were more likely to be independently mobile and live in their own home at the time of fracture (p<0.001). Pathological fractures were more common in younger patients and accounted for more than 1 in 20 fractures. Mortality at 30 and 120 days was significantly lower (p<0.0001) in the study cohort, however it was increased compared to age and gender adjusted mortality rates for the general population (p<0.001) Younger patients were more likely to recover independent mobility and living. CONCLUSION Patients aged 50-64 years have significantly better outcome measures after surgery for hip fracture in terms of survival and function. Such differences exist even after controlling for differences in patient case-mix variables.

Outcome After Sequential Hip Fracture in the Elderly

BACKGROUND Hip fracture is a common cause of morbidity and mortality in the elderly. As the risk factors for hip fracture often persist after the original injury, patients remain at risk for sequential fractures. Our aim was to report the incidence, epidemiology, and outcome of sequential hip fracture in the elderly. METHODS Data were collected during the acute hospital stay and at 120 days after admission from twenty-two acute orthopaedic units across Scotland between January 1998 and December 2005. These data were analyzed according to two separate time periods: by six-month intervals up to eight years after the primary fracture and by twenty-day intervals for the first two years after the primary fracture. RESULTS The risk of sequential fracture was highest in the first twelve months, affecting 3% of surviving patients and decreasing to 2% per survival year thereafter. Survival to twelve months after sequential fracture was 63% compared with 68% for those with a single fracture (p = 0.03). Sequential hip fracture was also associated with greater loss of independent mobility and changes in residential status compared with single fractures. CONCLUSIONS Sequential hip fracture is a relatively rare injury. Individuals who sustain this injury combination have poorer outcomes both in terms of survival and functional status. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Ethical Dilemmas in Orthopaedic Surgical Training

The involvement of surgical trainees in surgical procedures forms an integral part of traditional orthopaedic surgical education. While the need to train surgeons is unquestioned, a patient may not necessarily benefit from receiving treatment from an inexperienced surgeon and, indeed, may suffer a poorer outcome as a consequence1-7. As such, the process of orthopaedic surgical training is one that highlights a number of important ethical issues. While the ethical implications of clinical research have been the subject of extensive discussion and guideline development, the ethics of surgical training has received comparatively little attention8-10. Both clinical research and surgical training are analogous in that each involves participation in a process that, while potentially benefiting society as a whole, may result in harm to the individual. In this paper, we discuss the ethical issues that are salient to orthopaedic surgical training and examine how recent technological innovations may offer a potential solution to such issues. While medical ethics is a complex topic, it is fundamentally a code of professional conduct, commonly based on the four principles described by Beauchamp and Childress11. These principles are nonmaleficence, beneficence, autonomy, and justice. Nonmaleficence means that doctors have a basic obligation not to inflict harm on their patients, either intentionally or carelessly. Harm in terms of bioethics refers to physical harm such as pain, disability, or death. Unfortunately, all surgical interventions inevitably cause some harm and unavoidable risk, so this principle is impossible to guarantee. Beneficence refers to the principle of intervening to benefit the well-being of an individual. As surgeons, this basic principle is what we try to achieve in every procedure we undertake. Beauchamp and Childress highlight the differences between the principles of nonmaleficence and beneficence. The duty to “do no harm” invariably prohibits …

Is it worth screening elective orthopaedic patients for carriage of Staphylococcus aureus? A part-retrospective case-control study in a Scottish hospital.

Background With recent focus on methicillin-resistant Staphylococcus aureus (MRSA) screening, methicillin-susceptible S. aureus (MSSA) has been overlooked. MSSA infections are costly and debilitating in orthopaedic surgery. Methods We broadened MRSA screening to include MSSA for elective orthopaedic patients. Preoperative decolonisation was offered if appropriate. Elective and trauma patients were audited for staphylococcal infection during 2 6-month periods (A: January to June 2013 MRSA screening; B: January to June 2014 MRSA and MSSA screening). Trauma patients are not screened presurgery and provided a control. MSSA screening costs of a modelled cohort of 500 elective patients were offset by changes in number and costs of MSSA infections to demonstrate the change in total health service costs. Findings Trauma patients showed similar infection rates during both periods (p=1). In period A, 4 (1.72%) and 15 (6.47%) of 232 elective patients suffered superficial and deep MSSA infections, respectively, with 6 superficial (2%) and 1 deep (0.3%) infection among 307 elective patients during period B. For any MSSA infection, risk ratios were 0.95 (95% CI 0.41 to 2.23) for trauma and 0.28 (95% CI 0.12 to 0.65) for elective patients (period B vs period A). For deep MSSA infections, risk ratios were 0.58 (95% CI 0.20 to 1.67) for trauma and 0.05 (95% CI 0.01 to 0.36) for elective patients (p=0.011). There were 29.12 fewer deep infections in the modelled cohort of 500 patients, with a cost reduction of £831 678 for 500 patients screened. Conclusions MSSA screening for elective orthopaedic patients may reduce the risk of deep postoperative MSSA infection with associated cost-benefits.