Rate of Complications after Hip Fractures Caused by Prolonged Time-to-Surgery Depends on the Patient's Individual Type of Fracture and Its Treatment

INTRODUCTION

Hip fractures are common injuries in the elderly and are usually treated with timely surgery. While severe postoperative complications are reported for up to 10% of patients, many studies identified predictive factors for the occurrence of complications postoperatively. A controversially discussed factor is "time-to-surgery". The aim of the study was to examine if time-to-surgery was associated with the occurrence of complications and if the complication rate differed between the patient individual fracture types of intracapsular on the one hand and extracapsular hip fractures on the other hand. We hypothesized that time-to-surgery had less impact on complications in intracapsular hip fractures compared to extracapsular ones, and therefore, guidelines should pay attention to the patient individual case scenario.

MATERIALS AND METHODS

All patients who were admitted to the Department of Trauma and Orthopaedic Surgery of an academic teaching hospital for hip fracture surgery (n = 650) over a five-year period were included in the study. After the application of the exclusion criteria, such as periprosthetic or pathologic fractures, cases needed immediate surgical treatment, and after outlier adjustment, 629 cases remained in the study. Hip fractures were classified into intracapsular fractures (treated by hip arthroplasty) and extracapsular fractures (treated by intramedullary nailing osteosynthesis). The occurrence of severe complications in patients treated within 24 h was compared with patients treated later than 24 h after injury. For statistical evaluation, a multivariate logistic regression analysis was performed to investigate the impact of time-to-surgery interval on the occurrence of complications.

RESULTS

Patients with an extracapsular fracture, which was treated with intramedullary nailing (44.5%), rarely suffered a serious complication when surgery was performed within 24 h after injury. However, when the interval of the time-to-surgery was longer than 24 h, the complication rate increased significantly (8.63% vs. 25.0%, p = 0.002). In contrast to this finding in patients with intracapsular fractures (55.5%), which were treated with cemented arthroplasty, complication rates did not depend on the 24 h interval (26.17% vs. 20.83%, p = 0.567).

CONCLUSIONS

The occurrence of complications after surgical treatment of hip fractures is associated with the time interval between injury and surgery. A 24 h time interval between injury and surgical procedure seems to play a major role only in extracapsular fractures treated with osteosynthesis but not in intracapsular fractures treated with arthroplasty. Therefore, guidelines should take notice of the patient individual case scenario and, in particular, the individual hip fracture type.

Biomechanical comparison of different implants for PIP arthrodesis

BACKGROUND

Surgical correction of hammertoe deformities with arthrodesis of the proximal interphalangeal joint (PIP) is one of the most frequent forefoot procedures. Recently, new intramedullary fixation devices for PIP arthrodesis have been introduced. The aim of this study was to compare a newly developed absorbable intramedullary implant made of magnesium (mm.PIP), an already available intramedullary implant made of titanium (PipTree), and the classical Kirschner-wire (K-wire).

METHODS

The three intramedullary devices (mm.PIP, PipTree, and K-wire) for PIP arthrodesis were compared. A classical arthrodesis of the PIP joint was performed on fifty-four composite synthetic bone pairs. After arthrodesis, torsional load, weight-bearing and cyclic load tests were performed, and stability of the synthetic bone pairs was analyzed.

RESULTS

The mm.PIP was the most torsion resistant (mm.PIP vs. PipTree and K-wire, p < 0.001). The PipTree showed the best overall stability during cyclic weight-bearing simulation (PipTree vs. mm.PIP and K-wire, p < 0.001). K-wire demonstrated the highest breaking loads during bending tests (K-wire vs. mm-PIP and PipTree, p < 0.001).

CONCLUSION

Biomechanical properties of two new intramedullar implants, the bioresorbable mm.PIP made of magnesium and the PipTree made of titanium, were found to be comparable to the biomechanical properties of a K-wire which is commonly used for this procedure. Future work should be directed towards a clinical assessment of the bioabsorbable fixation devices for hammertoe procedures.

Stress shielding effect after total hip arthroplasty varies between combinations of stem design and stiffness-a comparing biomechanical finite element analysis

PURPOSE

Total hip arthroplasty (THA) has become a highly frequent orthopaedic procedure. Multiple approaches have been made to design the femoral component for THA with a mechanical behaviour as close as possible to a natural femur. The aim of this study was to compare different combinations of design and biomechanical properties of THA prostheses and their impact on stress shielding of the periprosthetic bone.

METHODS

Virtual implantation of different stem designs (straight standard stem, straight short stem, anatomical short stem) by finite element analysis based on in vivo data from computer tomography was performed. For each stem, three grades of stiffness were generated, followed by a strain analysis.

RESULTS

Reduction of stem stiffness led to less stress shielding. Implantation of an anatomical short-stem prosthesis with low stiffness provided the most physiological strain-loading effect (p < 0.001).

CONCLUSION

A combination of a short and an anatomically designed stem with a low stiffness might provide a more physiological strain transfer during THA. Biomechanical properties of the femoral component for THA should be considered as a multifactorial function of dimensions, design, and stiffness.

The Level of Surface Coverage of Surgical Site Disinfection Depends on the Visibility of the Antiseptic Agent-A Virtual Reality Randomized Controlled Trial

BACKGROUND

Surgical site infections (SSIs) have a significant impact on outcome associated with surgical treatment. Therefore, skin antisepsis has evolved as a standard preoperative procedure in the operating room to reduce the perioperative risk of an SSI. In their "Global Guidelines for the prevention of surgical site infections", the World Health Organization (WHO) recommend the use of an agent with remanent additives and considers colored agents as helpful. However, colored and remanent disinfectants are not available in Germany. The aim of the present study was to investigate whether using a colored antiseptic solution increases the quality of preoperative skin antisepsis.

METHODS

This study was designed as a randomized, double-blinded controlled trial. To examine the level of coverage of skin antisepsis, an appropriate virtual reality (VR) environment was generated. Participants could see a movable surgical clamp with a swab in their hand. When touching the skin, the participants recognized an optical change in the appearance of the skin: Using a colored antiseptic solution resulted in orange-colored skin. Using an uncolored agent, a shiny wet look was visible without a change in natural skin color.

RESULTS

Data of 141 participants (female: 61.0% (n = 86); mean age: 28 y (Range 18-58 y, SD = 7.53 y)) were included in the study. The level of disinfection coverage was higher in the group using the colored disinfectant. On average, 86.5% (sd = 10.0) of the leg skin was covered when a colored disinfectant was used, whereas only 73.9% (sd = 12.8) of the leg skin was covered when the participants had to use an uncolored agent (p < 0.001, effect size: f = 0.56, η2 = 0.24).

CONCLUSIONS

The use of an uncolored disinfectant leads to a lower surface coverage of the perioperative skin disinfection. Thus far, it is unclear whether using uncolored disinfectants is associated with higher risks for perioperative infections compared with the use of non-remanent disinfectants. Therefore, further research is necessary and current German guidelines should be re-evaluated accordingly.

Hospital volume-outcome relationship in total knee arthroplasty: protocol for a systematic review and non-linear dose-response meta-analysis

BACKGROUND

Knee osteoarthritis is a common, chronic condition and main contributor to global disability. Total knee arthroplasty (TKA) is the most successful treatment for end-stage knee osteoarthritis. It is assumed that in the field of surgery, there is a relationship between hospital volume and health outcomes and that higher hospital volume results in better health outcomes. As a consequence, minimum volume thresholds have been implemented in Germany for various procedures, including TKA (50 procedures per year). To date, it is unclear whether minimum volume thresholds truly result in better outcomes. The objective of this study will be to quantify the relationship between hospital volume and patient-relevant outcomes in patients undergoing TKA.

METHODS

We will include published or unpublished (cluster-) randomized controlled trials and prospective or retrospective cohort studies that involve patients with primary and/or revision TKA, report at least two different hospital volumes and report at least one patient-relevant outcome. To identify studies, we will systematically search (from inception onwards) PubMed/MEDLINE, Embase, CENTRAL, and CINAHL, as well as trial registers, conference proceedings, and reference lists. We will also contact experts in the field. Study selection and data extraction will be performed by two reviewers independently. The primary outcome will be rate of early revision. Secondary outcomes will include rate of revision > 1 year, mortality, length of stay, readmission rate, surgical complications, adverse events and health-related quality of life. We will assess the risk of bias of the included studies using ROBINS-I or the Cochrane risk of bias tool. Both a linear and a non-linear dose-response meta-analyses will be performed. We will use the GRADE approach to evaluate our confidence in the cumulative evidence. We will incorporate patients' needs, goals and preferences into our recommendations by consulting three focus groups, each consisting of eight participants.

DISCUSSION

The findings of our systematic review will probably be limited by the design of the included studies. We do not expect to identify any (cluster-) randomized controlled trials that meet our inclusion criteria. Therefore, the best available evidence included in our systematic review will most likely consist of cohort studies only. We anticipate that the results of this study will inform future health policy decisions in Germany regarding the minimum volume threshold for TKA. Systematic review registration: PROSPERO CRD42019131209.

Gender differences in blood transfusion strategy for patients with hip fractures - a retrospective analysis

Background: In the last decades, transfusion therapy with allogenic blood has progressively shifted to a more restrictive approach. The current study analyzed the transfusion practice and transfusion-associated factors in a regional trauma center over the course of five years. Methods: Retrospective analysis of all patients undergoing surgery for hip fractures in a level 1 trauma center of an academic teaching hospital from 2010 to 2014 (n=650). The number of transfused packed red blood cells (PRBCs), preoperative Hb concentrations, and intensive care unit (ICU) and hospital length of stay (LOS) were analyzed. A logistic regression analysis was performed to evaluate transfusion and ICU LOS-associated risk factors. (Ethical Review Board approval: 2015-497-f-S). Results: From 2010 to 2014 the average number of PRBCs transfused per patient decreased continuously despite similar preoperative Hb levels. During the same period, ICU LOS increased while hospital LOS decreased. Advanced patient age, preoperative Hb concentrations, surgical complications, and ICU LOS were associated with increased transfusion requirements. Although preoperative Hb levels were lower, females received fewer PRBCs compared to males. Conclusion: Over the course of five years, a restrictive transfusion strategy was implemented within clinical practice in patients undergoing surgery for hip fractures. In parallel, a significant reduction in the hospital LOS and an increased ICU LOS was noted. Whether there is an association between increased ICU LOS and decreasing hospital LOS and whether there is a gender effect on transfusion requirements in patients with surgery for hip fractures should be subject to further research.

Efficiency of platelet-rich plasma therapy in knee osteoarthritis does not depend on level of cartilage damage

OBJECTIVES

Osteoarthritis of the knee is common and often leads to significant physical disability. While classic conservative therapeutic approaches aim for symptoms like pain and inflammation, procedures like the intraarticular application of hyaluronic acids (HA) or platelet-rich plasma (PRP) are thought to stimulate the endogenous HA production, stop catabolism of cartilage tissue, and promote tissue regeneration. To analyse whether the positive effects of PRP injections are associated with the level of cartilage damage, patient satisfaction with the treatment was correlated with the level of knee joint osteoarthritis quantified by MRI.

METHODS

PRP was performed with a low-leukocyte autologous conditioned plasma (ACP) system in 59 patients. A pre-treatment MRI was performed and a Whole-Organ MRI Score (WORMS) was used to score the level of knee osteoarthritis by 14 features: integrity of the cartilage, affection of the bone marrow, subcortical cysts, bone attrition, osteophytes, integrity of the menisci and ligaments, presence of synovitis, loose bodies, and periarticular cysts. A multivariate analysis with ordinary least squares regressions was used.

RESULTS

Although pain symptoms and severity of clinical osteoarthritis symptoms decreased, regression analysis could not detect a correlation between the degree of cartilage damage measured by the WORMS score and a positive response to PRP therapy.

CONCLUSION

This study suggests that intraarticular injection of PRP might improve osteoarthritis symptoms and reduces the pain in patients suffering from osteoarthritis of the knee joint independent from the level of cartilage damages quantified by the whole-organ MRI scoring method WORMS.

Influence of Time to Surgery in Ankle Fractures on the Rate of Complications and Length of Stay - a Multivariate Analysis

BACKGROUND

With an incidence of 9/1000 per year, ankle fracture is one of the most common skeletal injuries. It is currently unclear whether time to surgery affects the complication rate or the hospital length of stay and whether there are confounders in patient characteristics or comorbidities.

MATERIAL AND METHODS

In a retrospective cohort study (n = 421), the risk of perioperative complications in patients with a primary operative fracture treatment within 6 hours of trauma was compared to a secondary surgical treatment. Furthermore, the influence of patient characteristics and comorbidities was examined in a multivariate regression analysis.

RESULTS

In comparison to secondary therapy, there was no benefit of a surgical fracture treatment within 6 hours after trauma was detected with regard to the perioperative complication rate or the hospital length of stay. Advanced patient age and severe soft tissue damage were associated with prolonged hospital length of stay but not with an increased rate of local perioperative complications.

CONCLUSION

The occurrence of severe local perioperative complications after surgical treatment of an ankle fracture is not associated with the time to surgery or covariates such as patient age or comorbidities. Current German guidelines for ankle fractures recommend surgical treatment within 6 - 8 hours, but these should be re-evaluated in further prospective randomised studies.

Biomechanics of common fixation devices for first tarsometatarsal joint fusion-a comparative study with synthetic bones

BACKGROUND

Hallux valgus disease is a common deformity of the forefoot. There are currently more than 100 surgical approaches for operative treatment. Because hypermobility of the first tarsometatarsal joint is considered to be causal for hallux valgus disease, fusion of the tarsometatarsal joint is an upcoming surgical procedure. Despite the development of new and increasingly stable fixation devices like different locking plates, malunion rates have been reported in 5 to 15% of cases.

METHODS

Biomechanical comparison of three commonly used fixation devices (a dorsal locking plate, a plantar locking plate, and an intramedullary fixation device) was performed by weight-bearing simulation tests on synthetic bones. Initial compression force and stiffness during simulation of postoperative weight-bearing were analysed.

RESULTS

Fixation of the first tarsometatarsal joint with the plantar plate combination demonstrated a higher stiffness compared to fixation with the intramedullary implant or the medial locking plate. The intramedullary device provided the highest initial compression force. Failure was detected in the following ranking: (1) the angle-stable intramedullary fixation device, (2) the medial located plate, and (3) the plantar locking plate.

CONCLUSION

The intramedullary device demonstrated the highest initial compression force of the three tested implants. The plantar locking plate showed the best overall stability during weight-bearing simulation. Further clinical research is necessary to analyse if the intramedullary fixation device needs a longer period of non-weight-bearing to reach a better non-union rate compared to the plantar locking plate.

Computer-aided planning with exact implementation into surgical technique in TKA is as accurate as intraoperative navigation

BACKGROUND

Exact positioning of implants and accuracy of alignment are important parameters to provide an long survivorship of endoprostheses after total knee arthroplasty. It was suggested that an alignment within 3∘ from centerline provides the best long-term survivorship of TKA. Therefore, computer-assisted navigation became more important in TKAs. Another tool to improve the accuracy in TKA is the preoperative planning software.

OBJECTIVE

Main goal was to determine if advantages of an intraoperative navigation system during TKA can be reached by an exact implementation of a preoperative computer-aided planning.

METHODS

Based on all patients (n= 100) underwent primarily TKA in 2015 and 2016 two groups were declared: (1) conventionally operated TKA without navigation system and (2) operation with an optical navigation system. Data on age, sex, date, operative time, severe complications and preoperative vs. postoperative alignment were collected retrospectively.

RESULTS

The two groups do not differ in postoperative alignment and frequency of outliers. Furthermore, there was no difference referring to complications and the length of stay in hospital, but operative time was prolonged in the navigation-assisted group.

CONCLUSIONS

It can be stated that conventional surgical techniques in TKA are as accurate as navigated ones if an exact preoperative computer aided planning is implemented during surgery.

Bone preserving level of osteotomy in short-stem total hip arthroplasty does not influence stress shielding dimensions - a comparing finite elements analysis

Background

The main objective of every new development in total hip arthroplasty (THA) is the longest possible survival of the implant. Periprosthetic stress shielding is a scientifically proven phenomenon which leads to inadvertent bone loss. So far, many studies have analysed whether implanting different hip stem prostheses result in significant preservation of bone stock. The aim of this preclinical study was to investigate design-depended differences of the stress shielding effect after implantation of a selection of short-stem THA-prostheses that are currently available.

Methods

Based on computerised tomography (CT), a finite elements (FE) model was generated and a virtual THA was performed with different stem designs of the implant. Stems were chosen by osteotomy level at the femoral neck (collum, partial collum, trochanter sparing, trochanter harming). Analyses were performed with previously validated FE models to identify changes in the strain energy density (SED).

Results

In the trochanteric region, only the collum-type stem demonstrated a biomechanical behaviour similar to the native femur. In contrast, no difference in biomechanical behaviour was found between partial collum, trochanter harming and trochanter sparing models. All of the short stem-prostheses showed lower stress-shielding than a standard stem.

Conclusion

Based on the results of this study, we cannot confirm that the design of current short stem THA-implants leads to a different stress shielding effect with regard to the level of osteotomy. Somehow unexpected, we found a bone stock protection in metadiaphyseal bone by simulating a more distal approach for osteotomy. Further clinical and biomechanical research including long-term results is needed to understand the influence of short-stem THA on bone remodelling and to find the optimal stem-design for a reduction of the stress shielding effect.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-017-1702-2) contains supplementary material, which is available to authorized users.

Volumetric measurement of periprosthetic bone remodeling: prospective 5 years follow-up after cemented total hip arthroplasty

INTRODUCTION

Periprosthetic bone remodeling after total hip arthroplasty (THA) is a well recognized phenomenon. Many authors have published osteodensitometric data with DEXA analysis. This study based on computerized tomography (CT).

MATERIALS AND METHODS

The objective of the current project is to collect prospective volumetric bone density data with a clinical CT study in six patients after cemented THA (titanium alloy stem). The follow-up time is 5 years. A data set of about 100,000 bone voxels for each femur was collected. Bone density was observed by dint of an osteodensitometric computer program. The median results were shown in seven regions of interest (ROI) around the prosthesis stem, according to Gruen.

RESULTS

The statistical analysis of the six cases after 60 months with respect to the postoperative control demonstrated a significantly lower density in ROI 2 (-125.5HU, P = 0.014), ROI 3 (-116.7HU, P = 0.023), ROI 4 (-54.5HU, P = 0.023), ROI 5 (-90.9HU, P = 0.014) and ROI 6 (-104.9HU, P = 0.014). Maximum density decrease was observed in ROI 2 and 3. The statistical analysis of the six cases after 60 months with respect to the 24 months control demonstrated a significantly lower density in ROI 2 (-62.6HU, P = 0.014), ROI 5 (-62.9HU, P = 0.023). There was a density decrease in ROI 3, 4, 6, 7 which was not significant and a slight increase in ROI 1.

CONCLUSION

To our knowledge, this is the first collection of fully prospective 5 years 3D periprosthetic density data. The CT method used in the study presented here measures three-dimensionally, while the frequently used DEXA (dual X-ray absorptiometry) method measures two-dimensionally. The data are also unique as they are suitable for direct patient-specific 3D finite element meshing and biomechanical calculation. They can be graphically post-processed in order to obtain cross-sectional or 3D displays of density patterns.

Femoral strain changes after total hip arthroplasty--patient-specific finite element analyses 12 years after operation

Periprosthetic stress-shielding after total hip arthroplasty (THA) is a well-known phenomenon. Many authors have used the finite element (FE) method to show the effects of THA on animal or human femora. In most cases they have performed cadaver experiments. The current project is a FE analysis based on a retrospective computerized tomography (CT) in vivo data set of 11 patients 12 years after THA. In order to control the analysis, a computationally created stem was implanted at the femur model of the not operated contralateral side. In comparison to the not operated side, there was a significant reduction of the strain energy density (SED) values in all regions of interest (ROI) with the greatest effect near the distal tip of the stem. Only zone 1 showed no clear trend which may be due to load application at the greater trochanter causing local strain peaks. The median SED values changed by -31.65% (ROI 1), -25.64% (ROI 2), -30.82% (ROI 3), -12.35% (ROI 4), -40.10% (ROI 5), -30.37% (ROI 6) and -43.38% (ROI 7). As far as we are aware, the current combination of in vivo CT density data with FE strain analyses after THA is based on the largest number of patients and the longest follow-up period. This combination enables analysis and prediction of the influence of implantation upon bone and can be compared with of remodelling theories. The assessment of mechanical strain data during a follow-up trial could be a new approach for analyzing different hip stems in clinical biomechanics.

[Stigmatization and quality of life of patients with psoriasis and atopic dermatitis]

BACKGROUND AND OBJECTIVE

Psoriasis and atopic dermatitis patients are often influenced by the psychosocial consequences of their skin diseases. In order to assess these experiences reliably, the stigmatization feeling and the quality of life of these patient groups were studied.

PATIENTS/METHODS

The short form of the "Questionnaire on Experience with Skin Complaints" (QES) was validated in a sample of 463 in-patients with psoriasis and atopic dermatitis. In addition, the Dermatology Life Quality Index (DLQI) was ascertained.

RESULTS

The dimensions "impairment of self-esteem and withdrawal", "rejection experienced", "concealment", and "composure" of the QES could be confirmed by factor analysis. As expected, middle high correlations between the QES and the DLQI were found in both patient groups. However, the stigmatization experience and the quality of life were not significantly different in a subgroup of psoriasis and atopic dermatitis patients with comparable sociodemographic characteristics.

CONCLUSIONS

The short form of the QES with 23 items is a valid instrument for the examination of social and psychic burdens of psoriasis and atopic dermatitis patients. The recording of the stigmatization feeling and of the quality of life determines different, supplementary aspects of the illness-related stress of patients with chronic skin diseases.