Search

INTRODUCTION: Osteomyelitis is an increasing burden on the society especially due to the emergence of multiple drug-resistant organisms. The lack of a central registry that prospectively collects data on patient risk factors, laboratory test results, treatment modalities, serological analysis results, and outcomes has hampered the research effort that could have improved and provided guidelines for treatments of bone infections. The current manuscript describes the lessons learned in setting up a multi-continent registry. MATERIALS AND METHODS: This multicenter, international registry was conducted to prospectively collect essential patient, clinical, and surgical data with a 1-year follow-up period. Patients 18 years or older with confirmed S. aureus long bone infection through fracture fixation or arthroplasty who consented to participate in the study were included. The outcomes using the Short Form 36 Health Survey Questionnaire (version 2), Parker Mobility Score, and Katz Index of Independence in Activities of Daily Living were assessed at baseline and at 1 month, 6 months, and 12 months. Serological samples were collected at follow-ups. RESULTS: Contract negotiation with a large number of study sites was difficult; obtaining ethics approvals were time-consuming but straightforward. The initial patient recruitment was slow, leading to a reduction of target patient number from 400 to 300 and extension of enrollment period. Finally, 292 eligible patients were recruited by 18 study sites (in 10 countries of 4 continents, Asia, North and South America, and Central Europe). Logistical and language barriers were overcome by employing courier service and local monitoring personnel. CONCLUSIONS: Multicenter registry is useful for collecting a large number of cases for analysis. A well-defined data collection practice is important for data quality but challenging to coordinate with the large number of study sites.

Recent health laws have shifted from the traditional fee-for-service model toward a pay-for-performance model. In this changing climate, it is imperative that a provider understands these changes and recognizes the importance of health services research on medicine.Increasing the value of care by improving quality and decreasing cost has been the focus of several projects. Preventing complications may be an effective way to increase value. Patient risk stratification is a modifiable variable that will allow for improved patient selection. This in turn may reduce adverse events, thereby lessening the economic burden of complications, increased length of stay, and hospital readmission. Providers must partner with their hospitals to align their goals and maximize quality and efficiency in order to decrease costs.

Additive manufacturing, also known as 3D printing, has emerged over the past 3 decades as a disruptive technology for rapid prototyping and manufacturing. Vat polymerization, powder bed fusion, material extrusion, and binder jetting are distinct technologies of additive manufacturing, which have been used in a wide variety of fields, including biomedical research and tissue engineering. The ability to print biocompatible, patient-specific geometries with controlled macro- and micro-pores, and to incorporate cells, drugs and proteins has made 3D-printing ideal for orthopaedic applications, such as bone grafting. Herein, we performed a systematic review examining the fabrication of calcium phosphate (CaP) ceramics by 3D printing, their biocompatibility in vitro, and their bone regenerative potential in vivo, as well as their use in localized delivery of bioactive molecules or cells. Understanding the advantages and limitations of the different 3D printing approaches, CaP materials, and bioactive additives through critical evaluation of in vitro and in vivo evidence of efficacy is essential for developing new classes of bone graft substitutes that can perform as well as autografts and allografts or even surpass the performance of these clinical standards.

Hip fractures are a common event in older adults and are associated with significant morbidity, mortality and costs. This review examines the necessary elements required to implement a successful geriatric fracture program and identifies some of the barriers faced when implementing a successful program. The Geriatric Fracture Center (GFC) is a treatment model that standardizes the approach to the geriatric fracture patient. It is based on five principles: surgical fracture management; early operative intervention; medical co-management with geriatricians; patient-centered, standard order sets to employ best practices; and early discharge planning with a focus on early functional rehabilitation. Implementing a geriatric fracture program begins with an assessment of the hospital’s data on hip fractures and standard care metrics such as length of stay, complications, time to surgery, readmission rates and costs. Business planning is essential along with the medical planning process. To successfully develop and implement such a program, strong physician leadership is necessary to articulate both a short- and long-term plan for implementation. Good communication is essential—those organizing a geriatric fracture program must be able to implement standardized plans of care working with all members of the healthcare team and must also be able to foster relationships both within the hospital and with other institutions in the community. Finally, a program of continual quality improvement must be undertaken to ensure that performance outcomes are improving patient care.

Readmission to the hospital following a hip fracture is common, often involves an adverse event, and strains an already overburdened health care system.To assess the rate of 30-day readmission to the hospital after discharge for care of hip fracture. A secondary objective was measurement of the 30-day mortality rate for those patients readmitted versus those patients not readmitted to the hospital after discharge.Study design was a retrospective review of registry data comparing readmitted patients to those not readmitted after hip fracture. Setting was a university affiliated level 3 trauma center.1,081 patients aged 65 and older.rate of readmission, rate of mortality, predictors of readmission.129 patients (11.9 %) were readmitted to the hospital within 30 days of their initial discharge date. The primary causes of readmission were surgical in nature for 24/129 (18.6 %) patients and 105/129 (81.4 %) were readmitted for medical or other reasons. Twenty-four (18.6 %) patients who were readmitted died during readmission. The one-year mortality rate for patients readmitted within 30 days was 56.2 vs. a 21.8 % 1-year mortality rate for those patients not readmitted (p 0.0001). Independent predictors of readmission were age85 (OR = 1.52; p = 0.03), time to surgery24 h (OR = 1.50; p = 0.05), Charlson score ≥4 (OR = 1.70; p = 0.04), delirium (OR = 1.65; p = 0.01), dementia (OR = 1.61; p = 0.01), history of arrhythmia with pacemaker placement (OR = 1.75; p = 0.02), and presence of a pre-op arrhythmia (OR = 1.62; p = 0.02).Readmission after hip fracture is harmful and undesirable-18.6 % of readmitted patients died during their readmission and the average length of stay was 8.7 days. Approximately one of every six readmissions was identified as potentially preventable with interventions.

This study compares re-operation rates and financial burden following the treatment of femoral neck fractures treated with hemiarthroplasty compared to non-displaced femoral neck fractures treated with cannulated screws.Data was retrospectively analyzed from a prospective database at a university hospital setting on patients undergoing hemiarthroplasty after femoral neck fractures and those with non-displaced femoral neck fractures treated with cannulated screws over a 7-year period. Re-operation rates were determined and financial data was analyzed. Charges refer to amounts billed by the hospital to insurance carriers, while costs refer to financial burden carried by the hospital during treatment.There were 491 femoral neck fractures (475 patients) that underwent hemiarthroplasty (HA) and 120 non-displaced fractures (119 patients) treated with cannulated screw (CannS) fixation. Both groups had similar age, sex, Charlson co-morbidity scores, pre-operative Parker mobility scores, and 12-month mortality. There were 29 (5.9 %) reoperations in the HA group and 16 (13.3 %) in the CannS group (P = 0.007). The majority of re-operations occurred within 12 months for both groups [21/29 (72 %) HA group; 15/16 (94 %) CannS group; P = 0.13]. Average hospital charges per patient for the index procedure were higher in the HA group ($17,880 ± 745) compared to the CannS group ($14,104 ± 5,047; P0.001). After accounting for additional procedures related to their initial surgical fixation, average hospital charges and costs remained higher in the HA group.Patients treated with hemiarthroplasty for femoral neck fractures have lower re-operation rates than patients treated with cannulated screws for non-displaced femoral neck fractures, with 80 % of re-operations occurring in the first 12 months. Hospital charges and costs to the hospital for treating patients undergoing hemiarthroplasty were higher than patients treated with cannulated screws for the index procedure alone, and after accounting for re-operations.

Stable fixation of periprosthetic or periimplant fractures with an angular stable plate and early weight bearing as tolerated. Periprosthetic femur fractures around the hip, Vancouver type B1 or C. Periprosthetic femur and tibia fractures around the knee. Periprosthetic fractures of the humerus. Periimplant fractures after intramedullary nailing. Loosening of prosthesis. Local infection. Osteitis. Preoperative planning is recommended. After minimally invasive fracture reduction and preliminary fixation, submuscular insertion of a large fragment femoral titanium plate or a distal femur plate. The plate is fixed with locking head screws and/or regular cortical screws where possible. If stability is insufficient, one or two locking attachment plates (LAP) are mounted to the femoral plate around the stem of the prosthesis. After fixing the LAP to one of the locking holes of the femoral plate, 3.5 mm screws are used to connect the LAP to the cortical bone and/or cement mantle of the prosthesis. Weight bearing as tolerated starting on postoperative day 1 is suggested under supervision of a physiotherapist. In 6 patients with periprosthetic fractures and 2 patients with periimplant fractures, no surgical complications (e.g., wound infection or bleeding) were observed. The mean time to bony union was 14 weeks. No implant loosening of the locking attachment plate was observed. At the follow-up examination, all patients had reached their prefracture mobility level.

Traumatic, cancerous or infectious loss of bone is treated by either amputation or reconstruction. With limb salvage always preferable, surgeons rely on already established techniques such as grafting and distraction osteogenesis to avoid amputation, and ideally restore structure and thus function. The Masquelet technique is an effective method of bone reconstruction and limb salvage which is underreported in the English literature, and we report a case with advances using a cage and nail construct, resulting in successful eradication of methicillin resistant staphylococcus aureus infection and reconstitution of a 17 cm diaphyseal defect in the tibia.

The geriatrician and orthopedic surgeon’s roles are well defined in hip fracture management, yet other health-care providers contribute significantly toward care, as well as maximizing rehabilitation potential and decreasing readmissions. We examine evidence concerning pre-hospital care, pain management, multidisciplinary rehabilitation and secondary prevention strategies. Cochrane reviews and randomized controlled trials were identified through PubMed to synthesize current evidence in the role of multidisciplinary management of the patient with a hip fracture from injury to secondary prevention. The well-recognized roles of the geriatrician, anesthetist and orthopedic surgeon were not evaluated for the purpose of this review. Transport of patients with a hip fracture can be eased through non-pharmaceutical simple, inexpensive techniques. Nerve blockade appears effective and easily administered in the emergency department. In-hospital multidisciplinary rehabilitation programs are effective in both earlier discharge and reducing falls, morbidity and mortality. Fall prevention programs are effective in nursing home patients, but not community dwellers. Osteoporosis prevention is primarily a medical endeavor; however, exercise and education may contribute to increased bone mineral density, compliance and better results of treatment. Multidisciplinary medical management of patients with hip fractures is being improved within the hospital environment resulting in earlier discharge with decreased morbidity. There is evidence to show the benefits to patients with hip fractures from peripheral modalities within the hospital; however unless resident in a facility, multidisciplinary management is not clearly of benefit.

Hip fractures in older adults are a common event with a high risk of morbidity and mortality. Patients who sustain a hip fracture often present with multiple co-morbid conditions that can benefit from co-management by orthopedic surgeons and geriatricians. This manuscript describes a co-managed model of care for patients with hip fractures. This model of care will be explained, and the benefits and results will be described. Retrospective review of the care of all native non-pathological hip fracture patients aged 60 years and older admitted between April 2005 and March 2009 to a 261-bed community teaching hospital. The outcome measures include patient characteristics, length of stay, mortality, 30-day readmission, re-operation, and costs of care. Seven hundred fifty-eight patients were identified with an average age of 84.8 (SD 8.4); 77.8% of the patients were female, 94.7% Caucasian, and 37.3% from nursing homes, and the mean Charlson score is 2.9 (SD 2.1). The length of stay was 4.3 days, 30-day readmission rate was 10.4%, 17-month re-operation rate was 1.9%, and costs of care to the system were $15,188. The 1-year mortality rate was 21.2%. This model of care resulted in improvements in all measures studied. Previous studies have shown reduction in in-hospital complications. Additional studies are needed to show if this model of care can be translated to other systems or to other surgical conditions. Wide application of this model care could substantially improve the quality of care and cost of caring for frail elders with hip fractures.

Low-energy fragility fractures account for >80% of fractures in elderly patients, and with aging populations, geriatric fracture surgery makes up a substantial proportion of the orthopedic workload. Elderly patients have markedly less physiologic reserve than do younger patients, and comorbidity is common. Even with optimal care, the risk of mortality and morbidity remains high. Multidisciplinary care, including early orthogeriatric input, is recommended to anticipate and treat complications. This article explores modern treatment strategies for this challenging group of patients and provides guidance for systematically preparing and optimizing elderly patients before surgery, based on best available current evidence and recommendations by relevant health organizations.