Recent Submissions

  • Effect of institution volume on mortality and outcomes in osteoporotic hip fracture care

    Johnson, NA (2022-01)
    Hospitals that treat more patients with osteoporotic hip fractures do not generally have better care outcomes than those that treat fewer hip fracture patients. Institutions that do look after more such patients tend, however, to more consistently perform relevant health assessments. INTRODUCTION: An inveterate link has been found between institution case volume and a wide range of clinical outcomes; for a host of medical and surgical conditions. Hip fracture patients, notwithstanding the significance of this injury, have largely been overlooked with regard to this important evaluation. METHODS: We used the UK National Hip Fracture database to determine the effect of institution hip fracture case volume on hip fracture healthcare outcomes in 2019. Using logistic regression for each healthcare outcome, we compared the best performing 50 units with the poorest performing 50 institutions to determine if the unit volume was associated with performance in each particular outcome. RESULTS: There were 175 institutions with included 67,673 patients involved. The number of hip fractures between units ranged from 86 to 952. Larger units tendered to perform health assessments more consistently and mobilise patients more expeditiously post-operatively. However, patients treated at large institutions did not have any shorter lengths of stay. With regard to most other outcomes there was no association between the unit number of cases and performance; notably mortality, compliance with best practice tariff, time to surgery, the proportion of eligible patients undergoing total hip arthroplasty, length of stay delirium risk and pressure sore risk. CONCLUSIONS: There is no relationship between unit volume and the majority of health care outcomes. It would seem that larger institutions tend to perform better at parameters that are dependent upon personnel numbers. However, where the outcome is contingent, even partially, on physical infrastructure capacity, there was no difference between larger and smaller units.
  • Management of Retraction Pockets: historic and novel approaches.

    Spinos, Dimitrios; Mallick, Sameer; Judd, Owen
  • Cervical arthroplasty in a professional kick-boxing fighter, 7 years follow-up.

    Klezl, Zdenek
    Spinal surgery in professional athletes is a topic of much discussion. Anterior cervical discectomy and fusion (ACDF) is the standard procedure used by surgeons, and other techniques used to treat athletes includes foraminotomies, laminoplasties and total disc replacement. Total disc replacement is an unusual technique used to treat athletes in general and is becoming a more important issue in full contact sports. This case report illustrates a 34 years old professional fighter that suffered a cervical injury that evolved with cervical axial pain and irradiated pain and numbness. She was submitted to total disc replacement (TDR) at the C5-6 level, returning to competitive sports after and with a seven-year follow-up. To the date she remains symptom free and besides having an anterior foramen, the spine was able to keep movement at that level. TDR may be a safe and trustworthy technique when treating elite athletes.
  • Myositis, Osteomyelitis and a Parasymphyseal Stress Fracture in a Paediatric Patient

    Hind, Jamie; Ashwood, Neil (Cureus, 2021)
    Abstract The limping child and painful hip are common presentations in many paediatric emergency units. Typically caused by mild self-limiting events, less commonly, they may be implicated in one of a group of inflammatory myopathies, or myositis. Diagnosis of this condition can be extremely difficult, and is aided by thorough clinical assessment, radiological imaging, and extensive blood serum testing. Myositis with associated osteomyelitis and a pathological fracture is an incredibly rare finding, described in this case report in a seven-year-old child.
  • Limb length inequality (LLI) is a frequent and recurring issue after total hip arthroplasty (THA). It is often a source of patient dissatisfaction and litigation. This study reviewed the incidence of LLI in a UK District General Hospital in light of published evidence and identified the preoperative and intraoperative risk factors for LLI.

    Abouelela, Amr; Mubark, Islam; Mohamed, Nagy; Jayakumar, Nithish; Ashwood, Neil; Bindi, Frank (2021)
    Abstract: Methods This was a retrospective study involving 380 consecutive unilateral primary total hip replacements over a period of 12 months. Patient demographics, clinical, radiological, and operative details were collected from the National Joint Registry (NJR) database and hospital records. The limb length was measured radiologically [OrthoView WorkstationTM (Materialise UK, Southampton, UK)], pre- and postoperatively, by two authors. They assessed the vertical distance between the intra-acetabular teardrop line and the medial apex of the lesser trochanters. After excluding complex primary, revision cases, tilted X-rays, and hip replacement for trauma patients, 338 cases were included in the final analysis. ResultsThe mean postoperative LLI was 2.7 mm with a standard deviation (SD) of 6.56 mm. Only 5.3% of patients had LLI >15 mm. None of the studied variables showed a statistically significant correlation with LLI. Even with the apparent difference in the mean LLI between templating and not templating before surgery (2.19 vs. 3.53), the p-value was 0.06, which was below the level of statistical significance. There was a weakly positive Pearson correlation between body mass index (BMI) and the incidence of lengthening of the limb. Conclusion The cause of LLI after THA is multifactorial. No single factor can be singled out as the most significant contributor to this complication.
  • Green Tea Extract Concurrent with an Oral Nutritional Supplement Acutely Enhances Muscle Microvascular Blood Flow without Altering Leg Glucose Uptake in Healthy Older Adults.

    Lund, Jonathan; Williams, John P (2021)
    Postprandial macro- and microvascular blood flow and metabolic dysfunction manifest with advancing age, so vascular transmuting interventions are desirable. In this randomised, single-blind, placebo-controlled, crossover trial, we investigated the impact of the acute administration of green tea extract (GTE; containing ~500 mg epigallocatechin-3-gallate) versus placebo (CON), alongside an oral nutritional supplement (ONS), on muscle macro- and microvascular, cerebral macrovascular (via ultrasound) and leg glucose/insulin metabolic responses (via arterialised/venous blood samples) in twelve healthy older adults (42% male, 74 ± 1 y). GTE increased m. vastus lateralis microvascular blood volume (MBV) at 180 and 240 min after ONS (baseline: 1.0 vs. 180 min: 1.11 ± 0.02 vs. 240 min: 1.08 ± 0.04, both p < 0.005), with MBV significantly higher than CON at 180 min (p < 0.05). Neither the ONS nor the GTE impacted m. tibialis anterior perfusion (p > 0.05). Leg blood flow and vascular conductance increased, and vascular resistance decreased similarly in both conditions (p < 0.05). Small non-significant increases in brachial artery flow-mediated dilation were observed in the GTE only and middle cerebral artery blood flow did not change in response to GTE or CON (p > 0.05). Glucose uptake increased with the GTE only (0 min: 0.03 ± 0.01 vs. 35 min: 0.11 ± 0.02 mmol/min/leg, p = 0.007); however, glucose area under the curve and insulin kinetics were similar between conditions (p > 0.05). Acute GTE supplementation enhances MBV beyond the effects of an oral mixed meal, but this improved perfusion does not translate to increased leg muscle glucose uptake in healthy older adults.
  • Two-Stage Primary Arthroplasty in the Infected Native Knee: A Systematic Review and Pooled Analysis.

    Mishra, Arya; Singh, Harvinder; Cockshott, S; Tambe, Amol (2021)
    INTRODUCTION: The knee is the commonest native joint to develop an infection. A two-stage primary knee replacement, with an interim stage of debridement and cement spacer application, modelled after two-stage revision for periprosthetic joint infections (PJI) has been reported for the management of chronic infections. AIMS: To systematically review the literature to find the infection-free survival and outcomes of this operation and explore its indications. METHODS: PRISMA guidelines were followed for this review. A systematic search of 4 online databases was conducted on 9/8/2020. After reviewing 226 abstracts and applying our selection criteria, 10 papers were selected for full-text review, and 9 included in the final synthesis. RESULTS: On pooled analysis, an infection-free survival of 95.6% (CI 94.7-96.4) was found at 2 years in 139 knees, which was unchanged over the remainder of the follow-up (Mean 3.9 years). The complication rate after final implantation was 6% in those that did not develop reinfection. The mean pooled Knee Society Score (KSS) and KSS Function score among 70 patients (4 papers) was 83.4 (80.1-89.0) and 76.8 (71.5-78.0), respectively. The mean range of motion among 82 patients (6 papers) was more than 100°. CONCLUSIONS: Two-stage primary knee replacement is a safe, effective and reliable procedure with good results in the short to medium term. Further studies are required to lay down precise indications and cost-effectiveness of this procedure, in comparison to other strategies for chronic infection. All joint registries should develop methods to identify patients undergoing two-stage procedures, to understand their long-term survival and outcomes.
  • SARS-CoV-2 infection is associated with an increased risk of idiopathic acute pancreatitis but not pancreatic exocrine insufficiency or diabetes: long-term results of the COVIDPAN study.

    Awan, Altaf (BMJ, 2021)
    SARS-CoV-2 infection is associated with an increased risk of idiopathic acute pancreatitis but not pancreatic exocrine insufficiency or diabetes: long-term results of the COVIDPAN study.
  • Postoperative arginine-enriched immune modulating nutrition: Long-term survival results from a randomised clinical trial in patients with oesophagogastric and pancreaticobiliary cancer.

    Iftikhar, Syed (Elsevier, 2021)
    BACKGROUND & AIMS: Immune modulating nutrition (IMN) has been shown to reduce postoperative infectious complications and length of stay in patients with gastrointestinal cancer. Two studies of IMN in patients undergoing surgery for head and neck cancer also suggested that this treatment might improve long-term survival and progression-free survival. In the present study, we analysed follow-up data from our previous randomised controlled trial of IMN, in patients undergoing surgery for oesophagogastric and pancreaticobiliary cancer, in order to evaluate the long-term impact on survival of postoperative IMN versus an isocaloric, isonitrogenous control feed. METHODS: This study included patients undergoing surgery for cancers of the pancreas, oesophagus and stomach, who had been randomised in a double-blind manner to receive postoperative jejunostomy feeding with IMN (Stresson, Nutricia Ltd.) or an isonitrogenous, isocaloric feed (Nutrison High Protein, Nutricia) for 10-15 days. The primary outcome was long-term overall survival. RESULTS: There was complete follow-up for all 108 patients, with 54 patients randomised to each group. There were no statistically significant differences between groups by demographics [(age, p = 0.63), sex (p = 0.49) or site of cancer (p = 0.25)]. 30-day mortality was 11.1% in both groups. Mortality in the intervention group was 13%, 31.5%, 70.4%, 85.2%, 88.9%, and 96.3% at 90 days, and 1, 5, 10, 15 and 20 years respectively. Corresponding mortality in the control group was 14.8%, 35.2%, 68.6%, 79.6%, 85.2% and 98.1% (p > 0.05 for all comparisons). CONCLUSION: Early postoperative feeding with arginine-enriched IMN had no impact on long-term survival in patients undergoing surgery for oesophagogastric and pancreaticobiliary cancer.
  • Safe Surgery During the COVID-19 Pandemic

    Madhok, Brijesh (2021)
    PURPOSE OF REVIEW: Coronavirus Disease-2019 (COVID-19) has had an enormous impact on all aspects of healthcare, but its effect on patients needing surgery and surgeons has been disproportionate. In this review, we aim to understand the impact of the pandemic on surgical patients and teams. We compiled the emerging data on pre-operative screening methods, vaccinations, safe-surgery pathways and surgical techniques and make recommendations for evidence-based safe-surgical pathways. We also present surgical outcomes for emergency, oncological and benign surgery in the context of the pandemic. Finally, we attempt to address the impact of the pandemic on patients, staff and surgical training and provide perspectives for the future. RECENT FINDINGS: Surgical teams have developed consensus guidelines and established research priorities and safety precautions for surgery during the COVID-19 pandemic. Evidence supports that surgery in patients with a peri-operative SARS-CoV-2 infection carries substantial risks, but risk mitigation strategies are effective at reducing harm to staff and patients. Surgery has increased risk for patients and staff, but this can be mitigated effectively, especially for elective surgery. Elective surgery can be safely performed during the COVID-19 pandemic employing the strategies discussed in this review.
  • Morphometric measurements can improve prediction of progressive vertebral deformity following vertebral damage.

    Annesley-Williams, DJ
    PURPOSE: A damaged vertebral body can exhibit accelerated 'creep' under constant load, leading to progressive vertebral deformity. However, the risk of this happening is not easy to predict in clinical practice. The present cadaveric study aimed to identify morphometric measurements in a damaged vertebral body that can predict a susceptibility to accelerated creep. METHODS: A total of 27 vertebral trabeculae samples cored from five cadaveric spines (3 male, 2 female, aged 36 to 73 (mean 57) years) were mechanically tested to establish the relationship between bone damage and residual strain. Compression testing of 28 human spinal motion segments (three vertebrae and intervening soft tissues) dissected from 14 cadaveric spines (10 male, 4 female, aged 67 to 92 (mean 80) years) showed how the rate of creep of a damaged vertebral body increases with increasing "damage intensity" in its trabecular bone. Damage intensity was calculated from vertebral body residual strain following initial compressive overload using the relationship established in the compression test of trabecular bone samples. RESULTS: Calculations from trabecular bone samples showed a strong nonlinear relationship between residual strain and trabecular bone damage intensity (R2 = 0.78, P < 0.001). In damaged vertebral bodies, damage intensity was then related to vertebral creep rate (R2 = 0.39, P = 0.001). This procedure enabled accelerated vertebral body creep to be predicted from morphological changes (residual strains) in the damaged vertebra. CONCLUSION: These findings suggest that morphometric measurements obtained from fractured vertebrae can be used to quantify vertebral damage and hence to predict progressive vertebral deformity.
  • A systematic review of total arthroplasty and arthrodesis for end-stage hallux rigidus: A biomechanical perspective.

    Rajan, Rowan; Mishra, Arya
    BACKGROUND: Both arthrodesis and total arthroplasty are acceptable surgical options for end stage hallux rigidus without significant angular deformity. Total arthroplasty preserves first metatarsophalangeal joint (MTPJ) motion, which may help restore a more physiological gait pattern. RESEARCH QUESTION: Is there a difference in the findings of gait studies after 1st MTPJ total arthroplasty or arthrodesis for end-stage hallux rigidus? METHODS: PRISMA guidelines were followed to conduct a systematic review of literature for studies reporting gait analysis after the above procedures. Predetermined criteria were used to select papers and evaluated the findings of kinematic (spatial-temporal and dynamic motion), kinetic and foot pressure (pedobarographic) studies. RESULTS: 12 titles were short-listed for synthesis. There was 1 randomized controlled trial comparing the two procedures. Among the remaining cohort studies, 5 reported on total arthroplasty and 6 on arthrodesis of the 1st MTPJ. Due to significant heterogeneity, a narrative synthesis was undertaken. No studies in the arthroplasty group reported spatial-temporal or kinetic parameters. Only 2 papers, 1 in each group, recorded motion within the foot. One of them showed preserved dynamic motion at the 1st MTPJ after total arthroplasty. Pedobarographic studies had discordant findings in studies within both groups regarding restoration of weight bearing through the medial forefoot and the pulp of the great toe during gait. CONCLUSION: Currently available studies are heterogenous and report inconsistent findings, which do not convincingly answer our research question. Prospective comparative studies with a large sample size, using standardized methodology in accredited laboratories with detailed reporting of kinetic, kinematic and pedobarographic components of gait analysis are required in order to draw concrete conclusions.
  • Minimum five-year outcomes of reverse total shoulder arthroplasty using a trabecular metal glenoid base plate

    Kankanalu, P; Borton, Zakk; Morgan, Marie; Cresswell, Timothy; Espag, Marius; Tambe, Amol; Clark, D (2021-08)
    AIMS: Reverse total shoulder arthroplasty (RTSA) using trabecular metal (TM)-backed glenoid implants has been introduced with the aim to increase implant survival. Only short-term reports on the outcomes of TM-RTSA have been published to date. We aim to present the seven-year survival of TM-backed glenoid implants along with minimum five-year clinical and radiological outcomes. METHODS: All consecutive elective RTSAs performed at a single centre between November 2008 and October 2014 were reviewed. Patients who had primary TM-RTSA for rotator cuff arthropathy and osteoarthritis with deficient cuff were included. A total of 190 shoulders in 168 patients (41 male, 127 female) were identified for inclusion at a mean of 7.27 years (SD 1.4) from surgery. The primary outcome was survival of the implant with all-cause revision and aseptic glenoid loosening as endpoints. Secondary outcomes were clinical, radiological, and patient-related outcomes with a five-year minimum follow-up. RESULTS: The implant was revised in ten shoulders (5.2%) with a median time to revision of 21.2 months (interquartile range (IQR) 9.9 to 41.8). The Kaplan-Meier survivorship estimate at seven years was 95.9% (95% confidence interval (CI) 91.7 to 98; 35 RTSAs at risk) for aseptic mechanical failure of the glenoid and 94.8% (95% CI 77.5 to 96.3; 35 RTSAs at risk) for all-cause revision. Minimum five-year clinical and radiological outcomes were available for 103 and 98 RTSAs respectively with a median follow-up time of six years (IQR 5.2 to 7.0). Median postoperative Oxford Shoulder Score was 38 (IQR 31 to 45); median Constant and Murley score was 60 (IQR 47.5 to 70); median forward flexion 115° (IQR 100° to 125°); median abduction 95° (IQR 80° to 120°); and external rotation 25° (IQR 15° to 40°) Scapular notching was seen in 62 RTSAs (63.2%). CONCLUSION: We present the largest and longest-term series of TM-backed glenoid implants demonstrating 94.8% all-cause survivorship at seven years. Specifically pertaining to glenoid loosening, survival of the implant increased to 95.9%. In addition, we report satisfactory minimum five-year clinical and radiological outcomes. Cite this article: Bone Joint J 2021;103-B(8):1333-1338.
  • Short-Term, Equipment-Free High Intensity Interval Training Elicits Significant Improvements in Cardiorespiratory Fitness Irrespective of Supervision in Early Adulthood.

    Doleman, Brett (2021-07)
    Introduction: Serious health implications from having low levels of cardiorespiratory fitness (CRF) and being overweight in young adulthood are carried forward into later life. High-intensity interval training (HIIT) is a time-effective, potent stimulus for improving CRF and indices of cardiometabolic health. To date, few studies have investigated the use of equipment-free HIIT or the impact of supervision for improving CRF via HIIT. Methods: Thirty healthy young adults (18-30 y) were randomised to 4 weeks (12 sessions) equipment-free, bodyweight based supervised laboratory HIIT (L-HIIT), unsupervised home HIIT (H-HIIT) or no-intervention (CON). Utilised exercises were star jumps, squats and standing sprints. Measurements of CRF (anaerobic threshold (AT) and VO2peak), blood pressure (BP), body mass index (BMI), blood glucose and plasma insulin by oral glucose tolerance test (OGTT), and muscle architecture were performed at baseline and after the intervention. Results: When compared to the control group, both HIIT protocols improved CRF (AT: L-HIIT mean difference compared to the control group (MD) +2.1 (95% CI: 0.34-4.03) ml/kg/min; p = 0.02; H-HIIT MD +3.01 (1.17-4.85) ml/kg/min; p = 0.002), VO2peak: L-HIIT (MD +2.94 (0.64-5.25) ml/kg/min; p = 0.01; H-HIIT MD +2.55 (0.34-4.76) ml/kg/min; p = 0.03), BMI (L-HIIT MD -0.43 (-0.86 to 0.00) kg/m2; p = 0.05; H-HIIT: MD -0.51 (-0.95 to -0.07) kg/m2; p = 0.03) and m. vastus lateralis pennation angle (L-HIIT MD 0.2 (0.13-0.27)°; p < 0.001; H-HIIT MD 0.17 (0.09 to 0.24)°; p < 0.001). There was no significant change in BP, blood glucose or plasma insulin in any of the groups. Conclusions: Four weeks time-efficient, equipment-free, bodyweight-based HIIT is able to elicit improvements in CRF irrespective of supervision status. Unsupervised HIIT may be a useful tool for counteracting the rise of sedentary behaviours and consequent cardiometabolic disorders in young adults.
  • Subclavian Artery Perforation and Mediastinal Hematoma Following Transradial Percutaneous Coronary Intervention.

    Gulsin, Gaurav; Taqi, Hussein; Azeem, Tariq (2021-06)
    We present a case of subclavian artery perforation with mediastinal hematoma following elective percutaneous coronary intervention. A conservative approach was preferred over invasive correction. Although no outcome data exist specifically for subclavian artery injury, registry data in patients with iatrogenic aortic dissection suggest that long-term outcomes are good without vascular repair. (Level of Difficulty: Advanced.).
  • Patellar resurfacing during primary total knee replacement is associated with a lower risk of revision surgery.

    Howard, Peter
    AIMS: Debate remains whether the patella should be resurfaced during total knee replacement (TKR). For non-resurfaced TKRs, we estimated what the revision rate would have been if the patella had been resurfaced, and examined the risk of re-revision following secondary patellar resurfacing. METHODS: A retrospective observational study of the National Joint Registry (NJR) was performed. All primary TKRs for osteoarthritis alone performed between 1 April 2003 and 31 December 2016 were eligible (n = 842,072). Patellar resurfacing during TKR was performed in 36% (n = 305,844). The primary outcome was all-cause revision surgery. Secondary outcomes were the number of excess all-cause revisions associated with using TKRs without (versus with) patellar resurfacing, and the risk of re-revision after secondary patellar resurfacing. RESULTS: The cumulative risk of all-cause revision at ten years was higher (p < 0.001) in primary TKRs without patellar resurfacing (3.54% (95% confidence interval (CI) 3.47 to 3.62)) compared to those with resurfacing (3.00% (95% CI 2.91 to 3.11)). Using flexible parametric survival modelling, we estimated one 'excess' revision per 189 cases performed where the patella was not resurfaced by ten years (equivalent to 2,842 excess revisions in our cohort). The risk of all-cause re-revision following secondary patellar resurfacing was 4.6 times higher than the risk of revision after primary TKR with patellar resurfacing (at five years from secondary patellar resurfacing, 8.8% vs 1.9%). CONCLUSION: Performing TKR without patellar resurfacing was associated with an increased risk of revision. Secondary patellar resurfacing led to a high risk of re-revision. This represents a potential substantial healthcare burden that should be considered when forming treatment guidelines and commissioning services. Cite this article: Bone Joint J 2021;103-B(5):864-871.

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