Introduction: Open reduction in Developmental Dysplasia of the hip (DDH) is regularly performed despite screening programmes, due to failure of treatment or late presentation. A protocol for open reduction of DDH has been refined through collaboration between surgical, anaesthetic and nursing teams to allow same day discharge. The objective of this study was to determine the safety and feasibility of performing open reduction of DDH as a day case. To our knowledge there is no previous description of open reduction as a day-case available in the literature.
Methods: All consecutive surgical cases of DDH between June 2015 and March 2020 were prospectively collected. Closed reductions, bilateral cases, cases requiring corrective osteotomy and children with co-morbidities were excluded. Data collected included demographics, safety outcome measures and feasibility for discharge according to the FLACC pain scale. A satisfaction questionnaire was filled by the carers.
Results: Out of 168 consecutive DDH cases, sixteen patients fitted the inclusion criteria (age range 10-26 months, 13 female). The intra-operative blood loss was minimal and there were no complications or re-admissions. The FLACC score was 0 for all patients. The carers satisfaction questionnaire expressed high satisfaction from the experience with adequate information and support.
Conclusions: Open reduction in DDH, without corrective osteotomy, is safe and feasible to be managed as a day case procedure. It requires a clear treatment pathway, analgesia, sufficient counselling and communication with carers. It is even more important in the COVID-19 reality when reduced length of hospital stay is likely to be safer.

Introduction: Slipped capital femoral epiphysis (SCFE) is the most common hip disorder in adolescents and has different methods of treatment. The purpose of this study was to explore the effects of different SCFE repair methods on postoperative complications within 30 days in nontraumatic patients. Methods: The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Pediatric database was queried with relevant ICD-9 and ICD-10 codes to identify patients who underwent surgery in 2012-2016 for nontraumatic SCFE. The selection of patients was further refined using current procedural terminology (CPT) codes by those who had traction without reduction, single/multiple pinning in situ, and open treatments. Patients were stratified by procedure and postoperative outcomes including complications, readmissions, reoperations, and extended length of stay. Results: 2606 nontraumatic SCFE patients were identified. 2495 (95.7%) had pinning in situ, 15 (0.6%) had open pinning, 27 (1.0%) had open osteoplasty of femoral neck, and 69 (2.6%) had open osteotomy with internal fixation. There were 18 (0.7%) patients who had complications, 27 (1.0%) required reoperations, and 5 (0.2%) were readmitted. Binary logistic regression analysis revealed patients that underwent open treatment of SCFE by osteoplasty of femoral neck (OR: 43.2 [12.6-147.9], p<0.001; OR=23.7 [10.8-52.1], p<0.001) and osteotomy with internal fixation (OR=15.3 [4.7-50.0], p<0.001; OR=32.7 [19.3-55.4) were significantly more likely to experience complications and an extended stay than patients with pinning in situ. Conclusion: Patients who had undergone SCFE repair by pinning in situ were significantly less likely to have complications and extended lengths of stay.

Background: The well accepted treatment of septic arthritis of the hip joint (SAHJ) is surgical drainage of the joint, but repeated aspirations of the hip joint under sonography, have been used for over twenty years with significant success. We have identified some children that did not respond to aspirations and had to undergo arthrotomies. The primary research question was to identify the characteristics of the non-responders, in order to improve our treatment algorithm.
Methods: A retrospective cohort analysis was performed. All the patients diagnosed with SAHJ between 2007-2019 were identified. Patients who responded to repeated aspirations were compared to those who did not improve and required surgery.
Results: Forty-eight children (88.9%) were treated successfully with repeated aspirations and 6 children (11.1%) did not improve after aspirations and underwent hip arthrotomies. Chronic comorbidities were found as a statistically significant parameter (p=0.0051), with 10.4% in the aspiration group and 66.7% in the arthrotomy group. The mean duration of fever above 38.5 and the length of stay were also found as statistically significant (p=0.0040, p=0.0301 respectively). When we examined the change in C-Reactive Protein levels before and after the first aspiration, we found a decrease in the aspiration group and an increase in the arthrotomy group (p=0.0044).
Conclusions: Children with SAHJ benefit from being treated with repeated joint aspirations, which is safe and effective. Patients with chronic comorbidities, prolonged fever and an increase in CRP level following the first aspiration, are at risk of treatment failure and should be treated with an arthrotomy.

Introduction: Fracture prediction is important in an ageing populations as effective prophylaxis exists. However, accurate prediction is difficult, with the local WHO fracture risk assessment tool (FRAX) reporting a sensitivity of 62.3% and positive predictive value of 10.3%. Artificial intelligence (AI) models have the advantage of exploring complex relationships among diverse patient and environmental risk factors over conventional statistical models. We set out to build a fracture prediction model to identify patients at risk of hip fracture within 5 years after an initial distal radius fracture. Methods: 43940 patients were included. 317 patient parameters were retrieved involving sociodemographics, medical comorbidities, blood test results, radiological investigations, healthcare utilisation, and drug prescriptions, with feature engineering performed. 35152 patients (80%) were used in model construction (i.e. training set), while a separate set of 8788 patients (20%) was used for model evaluation (i.e. test set for validation). An AI model was constructed through deep learning of an artificial neural network, with ReLU as activation function and Adam optimisation algorithm. This was validated and compared against a human model (constructed using conventional statistics) and FRAX. Results: The AI model (4-layer artificial neural network) demonstrated superior sensitivity (0.849 vs 0.846 vs 0.623), specificity (0.773 vs 0.626 vs 0.735), and area under curve (0.889 vs 0.788 vs 0.729) as compared to human model and FRAX respectively, which were statistically significant (p<0.001). Conclusion: Artificial intelligence could assist doctors in clinical practice to identify patients at risk of fracture and administer timely treatment to mitigate subsequent morbidity and mortality.

Hip fractures represent a significant burden to every Orthopaedic department. Acute gastrointestinal haemorrhage (AGIH) /stress ulceration is a postoperative complication associated with increased mortality. Stress ulcer prophylaxis such as the use of proton pump inhibitors (PPI) is an important measure to decrease this perioperative complication. Aims: This systematic review will aim to determine whether there is any benefit for patients with hip fractures being treated with prophylactic PPI medication to prevent AGIH and whether they reduce mortality. Methods: A systematic review of the literature was conducted according to PRISMA guidelines. Studies were identified according to the selection criteria and analysed using statistical software. Results: A total of 3 observational studies with 3413 participants met the criteria for inclusion. Patients taking PPIs had a reduced risk of an AGIH hip fracture than those without PPI therapy (RR 0.15 (95% CI 0.04–0.57, p < 0.0001).The use of PPIs in hip fracture patients shows a reduced mortality risk (RR 0.12 (95% CI 0.01–1.06, p < 0.0001). Conclusion: These results suggest that prophylactic PPI use in hip fracture patients is associated with a reduced risk of AGIH and also a reduced rate of mortality in this patient group. Orthopaedic surgeons should be aware of the risk of AGIH as a complication in hip fracture patients, knowledgeable to the factors which increase risk in their patient population and be cognisant that the prophylactic use of PPI medication is of benefit in reducing the complication of AGIH and correlates with a decreased mortality rate.

The primary aim was to assess the independent influence of COVID-19 on 30-day and 90-day mortality for patients with a neck of femur fracture(NOFF) and to determine the risk factors associated with mortality among these patients.
Methods:
All patients with NOFF with clinically or laboratory proven Covid-19 in 2020 were included. Patient demographics, type of residence, NEWS score on presentation, Nottingham Hip Fracture Score(NHF), Charlton comorbidity Index(CMI), time to surgery, operation, American Society of Anesthesiologists (ASA) grade, anesthetic, length of stay, COVID-19 status, and 30-day and 90-day mortality were recorded and compared among survivors and nonsurvivors.
Results
Of 273 patients with NOFF, 51 were diagnosed with COVID-19. The 30 day and 90day mortality among covid patients was 35.29%(18 patients) and 49.01%(25 patients). The mortality was particularly high among males(59%),Care home resident(75%), patients with NHF ≥ 5 (58.3%), AMTS<8 (59.1%)(p < 0.001). Though there was no difference in mean CMI, patients with Dementia(70.5%), COPD(64.3%), CVA (55.5%),, Liver Disease(100%), CKD(100%) had higher mortality. Patients who underwent surgery with Intramedullary nailing(66.6%) and DHS(75%) had higher mortality than Hemiarthroplasty(29.7%, p = 0.002). Delay in surgery of >48 hours had 100 % mortality. Higher NEWS on admission, ASA grade, length of stay, age made no statistically significant difference as a risk factor in mortality (p>0.05 ).
Conclusion
COVID-19 was independently associated with an increased 30-day and 90-day mortality rate for patients with a NOFF. Males, NHF ≥ 5, AMTS<8, Care home residents, delay in operation are independent risk factors leading to increased mortality.

The primary aim of this study was to evaluate the perioperative complications and postoperative functional scores of patients undergoing total joint arthroplasty on selective serotonin reuptake inhibitors (SSRI) and compare them with the patients not using SSRIs. A retrospective data analysis was performed on 28,386 patients. Functional scores were measured with the WOMAC and EQ-5D-5L questionnaires. Complications of interest were blood transfusion, readmission within 30 days, medical and mechanical events. This study demonstrated that patients on SSRIs have lower pre-operative baseline WOMAC and EQ-5D-5L scores than those not using SSRI (p < 0.001). All patients reported outcomes improved significantly following surgery but functional outcome scores remained inferior in patients using SSRI. After adjusting for age, sex, comorbidities, baseline functional outcome score, and procedure (TKA vs. THA) using regression analyses, at 12 months postoperatively, SSRI use in TKA predicted lower EQ-5D-5L scores than non SSRI users (p = 0.036) while the WOMAC scores were not different (p = 0.118). For the THA cohort, SSRI use predicted lower EQ-5D-5L (p = 0.001) and WOMAC scores than non SSRI users (p = 0.008). Our results showed increased transfusion rate, length of stay, readmission rate and medical events with SSRI utilization. We also found that 11.3% of TKA and 13.3% of THA patients stopped using SSRI at 12 months after arthroplasty. Patients using SSRIs show comparable overall improvement to patients not on SSRI, but their 12-month functional scores continue to be inferior. Further studies are necessary to determine appropriate preoperative optimization of these patients.