Background
Hip and spine pathology can alter the biomechanics of spino-pelvic mobility. Lumbar spine fusions can reduce the mobility of the lumbar spine and therefore result in compensatory femoral ...motion, contributing towards dislocations of THA.
Purpose
This meta-analysis aims to determine the effect of pre-existing spine fusions on THA outcomes, and complication profile including hip dislocations, all-cause revisions and all complications.
Methods
A multi-database search was performed according to PRISMA guidelines. All studies that compared patients who underwent THA with and without prior SF were included in the analysis.
Results
Ten studies were included in this review, consisting of 28,396 SF THA patients and 1,550,291 non-SF THA patients. There were statistically significant higher rates of hip dislocation (OR 2.20, 95% CI 1.71–2.85,
p
< 0.001), all-cause revision (OR 3.43, 95% CI 1.96–6.00,
p
< 0.001) and all complications (OR 2.83, 95% CI 1.28–6.24,
p
= 0.01) in SF than in non-SF THA patients. When registry data were excluded, these rates were approximately doubled. Subgroup analysis of revisions for dislocations was not statistically significant (OR 5.28, 95% CI 0.76–36.87,
p
= 0.09). While no meta-analysis was performed on clinical outcomes due to heterogeneous parameter reporting, individual studies reported significantly poorer outcomes in SF patients than in non-SF patients.
Conclusion
THA patients with SF are at higher risks of hip dislocations, all-cause revisions and all complications, which may adversely affect patient-reported outcomes. Surgeons should be aware of these risks and appropriately plan to account for altered spino-pelvic biomechanics, in order to reduce the risks of hip dislocations and other complications.
Level of evidence
II (Meta-analysis of non-homogeneous studies).
Graphic abstract
These slides can be retrieved under Electronic Supplementary Material.
Distal radial fractures represent one of the most common fractures in children with the majority treated by closed reduction and cast application. Redisplacement after manipulation can occur ...resulting in potential poor outcome. We performed a prospective study of children undergoing closed reduction of distal radial fracture and evaluated a range of possible risk factors contributing to loss of reduction.
The prospective study included 135 displaced distal radial fractures. There were 48 girls (36%) and 87 boys (64%), with a mean age of 9.9 years (range, 3 to 17 y). The risk factors for redisplacement, which were evaluated, were age, sex, location of the fracture, preoperative fracture displacement, presence of ulna fracture, grade of surgeon, quality of reduction, quality of plaster, and residual postreduction displacement.
Redisplacement occurred in 39 of 135 cases (28.8%). Initial complete displacement was the most important risk factor for loss of reduction (odds ratio, 6.94; P=0.001). Completely displaced fractures were 7 times more likely to redisplace than fractures with some bony contact or no translation. Achievement of anatomic reduction decreases the risk of redisplacement (odds ratio, 0.29; P=0.046). Ten of the 39 fractures that lost position needed a second procedure (7.4%).
Completely displaced distal radial fractures that cannot be anatomically reduced have a high risk of redisplacement after closed reduction. Only a small number of fractures that lose reduction will require a second intervention.
Level II.
Distal radius (wrist) fractures are the second most common fracture admitted to hospital. The anatomical pattern of these types of injuries is diverse, with variation in clinical management, ...guidelines for management remain inconclusive, and the uptake of findings from clinical trials into routine practice limited. Robust predictive modelling, which considers both the characteristics of the fracture and patient, provides the best opportunity to reduce variation in care and improve patient outcomes. This type of data is housed in unstructured data sources with no particular format or schema. The "Predicting fracture outcomes from clinical Registry data using Artificial Intelligence (AI) Supplemented models for Evidence-informed treatment (PRAISE)" study aims to use AI methods on unstructured data to describe the fracture characteristics and test if using this information improves identification of key fracture characteristics and prediction of patient-reported outcome measures and clinical outcomes following wrist fractures compared to prediction models based on standard registry data.
Adult (16+ years) patients presenting to the emergency department, treated in a short stay unit, or admitted to hospital for >24h for management of a wrist fracture in four Victorian hospitals will be included in this study. The study will use routine registry data from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR), and electronic medical record (EMR) information (e.g. X-rays, surgical reports, radiology reports, images). A multimodal deep learning fracture reasoning system (DLFRS) will be developed that reasons on EMR information. Machine learning prediction models will test the performance with/without output from the DLFRS.
The PRAISE study will establish the use of AI techniques to provide enhanced information about fracture characteristics in people with wrist fractures. Prediction models using AI derived characteristics are expected to provide better prediction of clinical and patient-reported outcomes following distal radius fracture.
Perioperative myocardial injury is common after major noncardiac surgery and is associated with adverse outcomes. This study investigated the use of ivabradine in patients undergoing urgent surgery ...for fracture.
This was a prospective, double-blind, placebo-controlled, randomized clinical trial. Participants were enrolled 1:1 into ivabradine or placebo arm, and study drug was commenced before operation and continued for 7 days or until discharge. High-sensitivity troponin I was measured daily using Abbott Alinity analyzer and assay, and heart rate data were obtained using continuous Holter monitoring. A total of 199 patients underwent acute orthopedic surgery, 98 in the ivabradine group and 101 in the placebo group. The mean age was 78.7 years (range, 77.5-79.9 years), with 68% women. The average heart rate was 5 to 11 beats per minute lower in the ivabradine group compared with the placebo group at all time points (
<0.001 for all). There was no statistically significant difference between the ivabradine and placebo groups in the number of patients who had perioperative myocardial injury: 28.6% versus 31.6% (
=0.71). In patients with perioperative myocardial injury, average peak troponin was 168.8 ng/L (±431.2 ng/L) in the ivabradine group and 2094.5 ng/L (±7201.9 ng/L) in the placebo group (
=0.16). There was no statistically significant difference between groups in 30-day mortality, blood pressure, stroke, or major adverse cardiovascular event.
Starting ivabradine preoperatively in elderly patients requiring acute surgery for fracture did not result in a statistically significant difference in the incidence of perioperative myocardial injury. There was no statistically significant difference in morbidity, mortality, or adverse events between treatment groups.
URL: https://www.anzctr.org.au/; Unique identifier: ACTRN12616001634460p.
To determine how much moderate-intensity physical activity, in the form of walking, could be prescribed for people living in the community after hip fracture in terms of safety, tolerability, and ...feasibility.
Phase I dose-response design.
Public community rehabilitation centers.
Community-dwelling adults (N=21; 16 women; mean age, 75±9y) who were cognitively alert, attending community rehabilitation after hip fracture (mean days postfracture, 110±47d), able to walk with or without a gait aid, and for whom it was safe to participate in physical activity.
Individually supervised doses of moderate-intensity walking completed in 1 week in addition to their usual levels of physical activity. Three participants were required to complete a dose of walking before dose escalation for the next cohort of 3 participants. Dose escalation ceased when >1 participant in a cohort had an adverse event or was unable to tolerate the dose or if the maximum dose of 150min/wk was achieved.
Maximum tolerated dose of walking per week (in minutes), adverse events, mobility, and walking confidence.
The maximum tolerated dose of walking for adults after hip fracture before significant discomfort was experienced (eg, breathlessness, pain, and fatigue) by any participant was 100min/wk. No adverse events occurred, but participants began to be unable to tolerate higher doses beyond 100min/wk.
This provides preliminary evidence that community-dwelling older adults recovering from hip fracture can complete a sufficient amount of moderate-intensity physical activity to maintain and improve their health.
Abstract Introduction The aim of this study was to review the complication rate and profile associated with surgical fixation of acute midshaft clavicle fracture in a large cohort of patients treated ...in a level I trauma centre. Patients and methods We identified all patients who underwent surgical treatment of acute midshaft clavicle fracture between 2002 and 2010. The study group consisted of 138 fractures (134 patients). There were 107 males (78%) and 31 females (22%) and median age of 35 years (IQR 24-45). The most common mechanism of injury was a road traffic accident (78%). Sixty percent (n = 83) had an injury severity score of ≥ 15 indicating major trauma. The most common fracture type (75%) was simple or wedge comminuted (2B1) according to the Edinburgh classification. The median interval between the injury and operation was 3 days (IQR 1-6). Plate fixation was performed in 110 fractures (80%) and intramedullary fixation was performed in 28 fractures (20%). There were 85 males and 25 females in the plate fixation group with median age of 35 years (IQR: 25-45) There were 22 males and 6 females in intramedullary fixation group with median age of 31 years (IQR 24-42 years). Statistical analysis was performed using Independent sample t-test, Mann-Whitney test, and Chi-square test. Significant P-value was < 0.05. Results The overall incidence of complication was 14.5% (n = 20). The overall nonunion rate 6%. Post operative wound infection occurred in 3.6% of cases. The incidence of complication associated with plate fixation was 10% (11 of 110 cases) compared to 32% associated with intramedullary fixation (9 of 28 cases) (P = 0.003). Thirty five percent of complications were related to inadequate surgical technique and potentially avoidable. Symptomatic hardware requiring removal occurred in 23% (n = 31) of patients. Symptomatic metalware was more frequent after plate fixation compared to intramedullary fixation (26% vs 7%, P = 0.03). Conclusions Intramedullary fixation of midshaft clavicle fracture is associated with higher incidence of complications. Plate fixation is associated with a higher rate of symptomatic metalware requiring removal compared to intramedullary fixation. Approximately one in three complications may be avoided by attention to adequate surgical technique.
Lipped or elevated acetabular liners are frequently used in total hip arthroplasty to improve stability. However, the optimal position of the lip is not known. The purpose of this study was to ...determine the optimal position of lipped acetabular liners in total hip arthroplasty performed with a posterior approach.
In 14 hips, lipped trial liners were placed intraoperatively in various positions around the posterior clock-face of the implanted acetabular shell component. For each liner position, stability of the hip was tested at maximal hip flexion with gradually increasing internal rotation until subluxation occurred, at which point the position of the hip was measured using smartphone accelerometer-based goniometers. Smartphone goniometers were first validated against a computer-assisted navigation system. Post-operative radiographs were analyzed for cup inclination angle, cup anteversion angle, and femoral offset.
Mean cup inclination angle in our series was 31° ± 6°. The most common liner position that imparted the greatest stability to posterior subluxation was posteriorly and inferiorly (4 o'clock position for left hip, or 8 o'clock position for right hip). The range for most stable liner position for different patients varied from postero-superior (11 o'clock/1 o'clock position) to directly inferior (6 o'clock position). Comparing a non-lipped liner to a lipped liner placed in the optimal position, the average difference in internal rotation gained before dislocation was 23°. There was no association between cup inclination or anteversion angle with liner position of greatest stability.
In hip replacements performed through a posterior approach and with mean cup inclination angle of 31° ± 6°, placing the lip of the elevated liner in the postero-inferior quadrant may impart more stability than in the postero-superior quadrant.
Closed reductions of distal radial fractures are among the most common orthopaedic operations but up to 39% of fractures lose position postoperatively. This study was carried out to determine the ...most significant risk factors for loss of position so that high-risk patients can be identified early and their management tailored accordingly.
We retrospectively reviewed 48 consecutive children who had redisplacement of their distal radial fractures after closed reduction and compared them with 48 matched controls. Fourteen risk factors were studied and analyzed with univariate and multivariate logistic regression analysis and receiver operating characteristics analysis. These risk factors included pre-reduction and post-reduction fracture characteristics as well as 4 previously described radiological indices of plaster quality.
Significant independent clinical risk factors identified were the initial radial fracture displacement odds ratio (OR) 1.03, P = 0.001 and obliquity (OR 0.93, P = 0.006), a completely displaced radial fracture (OR 5.21, P =0.003), an ipsilateral ulnar fracture (OR 3.56, P = 0.003), residual radial displacement (OR 1.06, P = 0.009), angulation (OR 1.16, P = 0.011), and failure to achieve anatomical reduction (OR 0.18, P = 0.004). Significant radiological indices included the Padding index (OR >100, P = 0.004), Canterbury index (OR 99, P = 0.014), and 3-point index (OR 19.29, P < 0.001). Nonsignificant risk factors included the angulation of the initial radial fracture, a completely displaced ulnar fracture, plaster changes/splitting and the Cast index. The combined preoperative presence of a completely displaced radial fracture, an ipsilateral ulnar fracture and failure to achieve perfect reduction was found to be the best predictor of redisplacement (receiver operating characteristic area under the curve=0.82). This combination was found to be a better predictor of redisplacement than any of the radiological indices (receiver operating characteristic area under the curve ≤ 0.74) and it is also a more practical risk factor for the operating surgeon to use.
The combination of a completely displaced distal radial fracture and an ipsilateral ulnar fracture, which then cannot be perfectly reduced, was the best predictor for redisplacement. We recommend that serious consideration be given to primary wire fixation in these patients.
III, prognostic.
IntroductionCommunity-dwelling people recovering from hip fracture have the physical capacity to walk in their community but lack the confidence to do so. The primary aim of this trial is to ...determine whether motivational interviewing increases time spent walking at 12 months in community-dwelling people after hip fracture compared with an attention placebo control group. Secondary aims are to evaluate cost effectiveness, patient and health service outcomes and to complete a process evaluation.Methods and analysisAn assessor-blinded parallel group randomised controlled design with embedded health economic evaluation and process evaluation will compare the effects of n=270 participants randomly allocated to an experimental group (motivational interviewing) or a control group (dietary advice). For inclusion, participants are aged ≥65 years, living at home independently within 6 months of discharge from hospital after hip fracture and able to walk independently and communicate with conversational English. Key exclusion criteria are severe depression or anxiety, impaired intellectual functioning and being medically unstable to walk. Participants allocated to the experimental group will receive 10 (8 weekly and 2 booster) telephone-based sessions of motivational interviewing to increase walking over 16 weeks. Participants allocated to the control group will receive an equivalent dose of telephone-based dietary advice. The primary outcome is daily time spent walking over 7 days assessed at weeks 0, 9, 26 and 52. Secondary outcomes include measures of psychological-related function, mobility-related function, community participation, health-related quality of life and falls. Health service utilisation and associated costs will be assessed. Process evaluation will assess the fidelity of the motivational interviewing intervention and explore contextual factors through semistructured interviews.Ethics and disseminationEthical approval obtained from Eastern Health (E19-002), Peninsula Health (50261/EH-2019), Alfred Health (617/20) and La Trobe University (E19/002/50261). The findings will be disseminated in peer-reviewed journals, conference presentations and public seminars.Trial registration numberACTRN12619000936123.
We are performing a combined randomised and observational study comparing internal fixation to non-surgical management for common wrist fractures in older patients. This paper describes the ...statistical analysis plan.
A Combined Randomised and Observational Study of Surgery for Fractures In the distal Radius in the Elderly (CROSSFIRE) is a randomised controlled trial comparing two types of usual care for treating wrist fractures in older patients, surgical fixation using volar locking plates and non-surgical treatment using closed reduction and plaster immobilisation. The primary aim of this comparative-effectiveness study is to determine whether surgery is superior to non-surgical treatment with respect to patient-reported wrist function at 12 months post treatment. The secondary outcomes include radiographic outcomes, complication rates and patient-reported outcomes including quality of life, pain, treatment success and cosmesis. Primary analysis will use a two-sample t test and an intention-to-treat analysis using the randomised arm of the study. Statistical analyses will be two-tailed and significance will be determined by p < 0.05. Sensitivity analyses will be conducted to assess for differences in intention-to-treat, per-protocol and as-treated analyses. Sensitivity analyses will also be conducted to assess selection bias by evaluating differences in participants between the randomised and observational study arms, and for bias relating to any missing data. An economic analysis will be conducted separately if surgery is shown to provide superior outcomes to a level of clinical significance.
This statistical analysis plan describes the analysis of the CROSSFIRE study which aims to provide evidence to aid clinical decision-making in the treatment of distal radius fractures in older patients.
CROSSFIRE was approved by The Hunter New England Human Research Ethics Committee (HNEHREC Reference No: 16/02/17/3.04). Registered on 22 July 2016 with The Australian and New Zealand Clinical Trials Registry (ANZCTR Number; ACTRN12616000969460 ). This manuscript is based on v.11 of the statistical analysis plan. A copy of v.11, signed by the chief investigator and the senior statistician is kept at the administering institution.
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