Explore the vast range of titles available.

Plan for long term disruption and enduring effects on healthcare staff

Background: Hip fracture is associated with high mortality among the elderly. Most patients require surgery, but the timing of the operation remains controversial. Surgery within twenty-four hours after admission has been recommended, but evidence supporting this approach is lacking. The objective of this study was to determine whether a delay in surgery for hip fractures affects postoperative mortality among elderly patients. Methods: We conducted a prospective, observational study of 2660 patients who underwent surgical treatment of a hip fracture at one university hospital. We measured mortality rates following the surgery in relation to the delay in the surgery and the acute medical comorbidities on admission. Results: The mortality following the hip fracture surgery was 9% (246 of 2660) at thirty days, 19% at ninety days, and 30% at twelve months. Of the patients who had been declared fit for surgery, those operated on without delay had a thirty-day mortality of 8.7% and those for whom the surgery had been delayed between one and four days had a thirty-day mortality of 7.3%. This difference was not significant (p = 0.51). The thirty-day mortality for patients for whom the surgery had been delayed for more than four days was 10.7%, and this small group had significantly increased mortality at ninety days (hazard ratio = 2.25; p = 0.001) and one year (hazard ratio = 2.4; p = 0.001). Patients who had been admitted with an acute medical comorbidity that required treatment prior to the surgery had a thirty-day mortality of 17%, which was nearly 2.5 times greater than that for patients who had been initially considered fit for surgery (hazard ratio = 2.3, 95% confidence interval = 1.6 to 3.3; p < 0.001). Conclusions: The thirty-day mortality following surgery for a hip fracture was 9%. Patients with medical comorbidities that delayed surgery had 2.5 times the risk of death within thirty days after the surgery compared with patients without comorbidities that delayed surgery. Mortality was not increased when the surgery was delayed up to four days for patients who were otherwise fit for hip fracture surgery. However, a delay of more than four days significantly increased mortality. Level of Evidence: Therapeutic Level II . See Instructions to Authors for a complete description of levels of evidence.

Background Hip fracture is a common injury in older people with a high rate of postoperative morbidity and mortality. This patient group is also at high risk of acute kidney injury (AKI) and chronic kidney disease (CKD), but little is known of the impact of kidney disease on outcome following hip fracture. Methods An observational cohort of consecutive patients with hip fracture in a large UK secondary care hospital. Predictive modelling of outcomes using development and validation datasets. Inclusion: all patients admitted with hip fracture with sufficient serum creatinine measurements to define acute kidney injury. Main outcome measures – development of acute kidney injury during admission; mortality (in hospital, 30-365 day and to follow-up); length of hospital stay. Results Data were available for 2848 / 2959 consecutive admissions from 2007-2011; 776 (27.2%) male. Acute kidney injury occurs in 24%; development of acute kidney injury is independently associated with male sex (OR 1.48 (1.21 to 1.80), premorbid chronic kidney disease stage 3B or worse (OR 1.52 (1.19 to 1.93)), age (OR 3.4 (2.29 to 5.2) for >85 years) and greater than one major co-morbidities (OR 1.61 (1.34 to 1.93)). Acute kidney injury of any stage is associated with an increased hazard of death, and increased length of stay (Acute kidney injury: 19.1 (IQR 13 to 31) days; no acute kidney injury 15 (11 to 23) days). A simplified predictive model containing Age, CKD stage (3B-5), two or more comorbidities, and male sex had an area under the ROC curve of 0.63 (0.60 to 0.67). Conclusions Acute kidney injury following hip fracture is common and associated with worse outcome and greater hospital length of stay. With the number of people experiencing hip fracture predicted to rise, recognition of risk factors and optimal perioperative management of acute kidney injury will become even more important.

ObjectiveTo examine whether the timing of delivery of intravenous antibiotics following open limb fractures has an effect on deep infection rates and other outcomes.DesignWe published an a priori study protocol in PROSPERO. Our search strategy combined terms for antibiotics, timing of administration and fractures. Two independent reviewers screened, selected, assessed quality and extracted data from identified studies.Data sourcesWe searched five electronic databases with no limits and performed grey literature searches.Eligibility criteria for selecting studiesRandomised and non-randomised controlled studies, prospective and retrospective observational studies in which the effect of the timing of delivery of antibiotics on the outcome of deep infection in open fractures was considered were included.ResultsEight studies were included according to the above criteria. There were no randomised or non-randomised controlled trials. None of the included studies provided data on patient reported or health-related quality of life. The overall deep infection rate ranged from 5% to 17.5%. All of the studies were at substantial risk of bias. One study reported a reduced infection rate with the delivery of antibiotics within 66 min of injury and seven studies reporting no effect.ConclusionsSufficiently robust evidence is not available currently to determine whether the timing of delivery of intravenous antibiotics has an effect on the risk of deep infection or other outcomes following open limb fractures. There is therefore a need for a randomised controlled trial in this area before policy changes should be instigated.Trial registration numberPROSPERO (CRD42015016729).

Introduction Multiligament knee injuries are uncommon but serious injuries. There is ongoing debate on the optimal treatment of these injuries. We designed a study to establish the effects of repair or reconstruction on proprioceptive outcomes following multiligament injury to the knee. Materials and Methods A total of 34 patients were analysed by independent researchers who had no conflict of interest in the cases (23 in the repair group and 11 in the reconstruction group). Proprioception of the knee was measured using a previously validated tool to assess the reproduction of passive positioning. Functional outcome was measured using the Lysholm score. Sub-group analysis was performed. The mean time from injury to review was 83 months (range: 25-193 months). Results There were no significant differences in proprioceptive acuity between the injured (5.9±4.2°; range: 1.0-18.3°) and uninjured contralateral (control) knees (5.2±3.8°; range: 1.0-15.0°; p=0.35). Similarly, there was no significant difference in proprioceptive acuity identified between the injured knees that underwent repair (6.0±4.3°; range: 1.0-18.3°) or reconstruction (5.0±3.6°; range: 1.3-14°; p=0.53). Overall knee outcomes were good; the mean Lysholm score at final follow-up was 75.5±16.8 (range: 36-100). No significant differences were identified in any of the sub-groups. Conclusions We were unable to identify any differences in knee proprioceptive acuity between injured knees and controls nor between the types of surgical treatment, demonstrating equivocal recovery for both methods of treatment.Introduction Multiligament knee injuries are uncommon but serious injuries. There is ongoing debate on the optimal treatment of these injuries. We designed a study to establish the effects of repair or reconstruction on proprioceptive outcomes following multiligament injury to the knee. Materials and Methods A total of 34 patients were analysed by independent researchers who had no conflict of interest in the cases (23 in the repair group and 11 in the reconstruction group). Proprioception of the knee was measured using a previously validated tool to assess the reproduction of passive positioning. Functional outcome was measured using the Lysholm score. Sub-group analysis was performed. The mean time from injury to review was 83 months (range: 25-193 months). Results There were no significant differences in proprioceptive acuity between the injured (5.9±4.2°; range: 1.0-18.3°) and uninjured contralateral (control) knees (5.2±3.8°; range: 1.0-15.0°; p=0.35). Similarly, there was no significant difference in proprioceptive acuity identified between the injured knees that underwent repair (6.0±4.3°; range: 1.0-18.3°) or reconstruction (5.0±3.6°; range: 1.3-14°; p=0.53). Overall knee outcomes were good; the mean Lysholm score at final follow-up was 75.5±16.8 (range: 36-100). No significant differences were identified in any of the sub-groups. Conclusions We were unable to identify any differences in knee proprioceptive acuity between injured knees and controls nor between the types of surgical treatment, demonstrating equivocal recovery for both methods of treatment.

Background With greater technological developments in the care of musculoskeletal patients, we are entering an era of rapid change in our understanding of the pathophysiology of traumatic injury; assessment and treatment of polytrauma and related disorders; and treatment outcomes. In developed countries, it is very likely that we will have algorithms for the approach to many musculoskeletal disorders as we strive for the best approach with which to evaluate treatment success. This debate article is founded on predictions of future health care needs that are solely based on the subjective inputs and opinions of the world's leading orthopedic surgeons. Hence, it functions more as a forum-based rather than a scientific-based presentation. This exposé was designed to stimulate debate about the emerging patients' needs in the future predicted by leading orthopedic surgeons that provide some hint as to the right direction for orthopedic care and outlines the important topics in this area. Discussion The authors aim to provide a general overview of orthopedic care in a typical developed country setting. However, the regional diversity of the United States and every other industrialized nation should be considered as a cofactor that may vary to some extent from our vision of improved orthopedic and trauma care of the musculoskeletal patient on an interregional level. In this forum, we will define the current and future barriers in developed countries related to musculoskeletal trauma, total joint arthroplasty, patient safety and injuries related to military conflicts, all problems that will only increase as populations age, become more mobile, and deal with political crisis. Summary It is very likely that the future will bring a more biological approach to fracture care with less invasive surgical procedures, flexible implants, and more rapid rehabilitation methods. This international consortium challenges the trauma and implants community to develop outcome registries that are managed through health care offices and to prepare effectively for the many future challenges that lie in store for those who treat musculoskeletal conditions.

A pelvic fracture usually indicates high energy transfer from a significant mechanism and a high likelihood of associated injuries. Mortality from pelvic trauma is usually due to massive haemorrhage mandating expedient resuscitation of the patient and immediate control of exsanguinating haemorrhage. Damage control resuscitation incorporates permissive hypotensive resuscitation and early replacement of clotting factors with early aggressive surgical control of bleeding. A commercially available pelvic binder provides circumferential compression and rapidly closes the pelvis, leading to fracture splintage and reduction in pelvic volume, both of which reduce haemorrhage. It is critical to distinguish ongoing bleeding due to a pelvic ring injury from intra-peritoneal haemorrhage. The identification of intra-peritoneal bleeding in a haemodynamically unstable patient mandates laparotomy. On-going haemorrhage from the pelvis requires diagnostic pelvic angiography, followed by selective embolisation if a source of bleeding is identified. If angiography is not available pelvic packing can be life-saving.

Hip fracture is associated with high mortality among the elderly. Most patients require surgery, but the timing of the operation remains controversial. Surgery within twenty-four hours after admission has been recommended, but evidence supporting this approach is lacking. The objective of this study was to determine whether a delay in surgery for hip fractures affects postoperative mortality among elderly patients. We conducted a prospective, observational study of 2660 patients who underwent surgical treatment of a hip fracture at one university hospital. We measured mortality rates following the surgery in relation to the delay in the surgery and the acute medical comorbidities on admission. The mortality following the hip fracture surgery was 9% (246 of 2660) at thirty days, 19% at ninety days, and 30% at twelve months. Of the patients who had been declared fit for surgery, those operated on without delay had a thirty-day mortality of 8.7% and those for whom the surgery had been delayed between one and four days had a thirty-day mortality of 7.3%. This difference was not significant (p = 0.51). The thirty-day mortality for patients for whom the surgery had been delayed for more than four days was 10.7%, and this small group had significantly increased mortality at ninety days (hazard ratio = 2.25; p = 0.001) and one year (hazard ratio = 2.4; p = 0.001). Patients who had been admitted with an acute medical comorbidity that required treatment prior to the surgery had a thirty-day mortality of 17%, which was nearly 2.5 times greater than that for patients who had been initially considered fit for surgery (hazard ratio = 2.3, 95% confidence interval = 1.6 to 3.3; p < 0.001). The thirty-day mortality following surgery for a hip fracture was 9%. Patients with medical comorbidities that delayed surgery had 2.5 times the risk of death within thirty days after the surgery compared with patients without comorbidities that delayed surgery. Mortality was not increased when the surgery was delayed up to four days for patients who were otherwise fit for hip fracture surgery. However, a delay of more than four days significantly increased mortality.