Now showing items 1-20 of 278

    • To plate, or not to plate? A systematic review of functional outcomes and complications of plate fixation in patellar fractures.

      Ilo, Kevin
      PURPOSE: Poor outcomes and high complication and reoperation rates have been reported with tension-band wiring (TBW) in the management of patellar fractures and particularly the comminuted ones. The purpose of this study was to investigate the functional outcomes and complication rates of patellar fractures managed with open reduction and internal fixation (ORIF) with a plate. METHODS: MEDLINE, EMCare, CINAHL, AMED and HMIC were searched, and the PRISMA guidelines were followed. Two independent reviewers extracted the data from the included studies and assessed them for the risk of bias. RESULTS: Plating of patellar fractures is associated with satisfactory range of movement (ROM) and postoperative function and low pain levels. We found a 10.44% complication rate and a low reoperation rate. Reoperations were mainly performed for metalwork removal. CONCLUSION: ORIF with plating of patellar fractures is a safe alternative in the management of patellar fractures and may be associated with a lower complication and reoperation rate compared to TBW. Future randomized prospective studies are needed to validated the results of the present systematic review.
    • Assessing the use of the frequency, etiology, direction, and severity classification system for shoulder instability in physical therapy research - A scoping review.

      Bateman, Marcus
      OBJECTIVE: The aim of this study is to review the implementation of the Frequency, Etiology, Direction, and Severity (FEDS) classification for shoulder instability by the physical therapy scientific community since its publication in 2011. METHODS: A systematic search was conducted on January 10, 2024 in the MEDLINE, EMBASE, SPORTDiscus, Scopus, Web of Science, Cochrane, and SciELO databases, as well as Google Scholar. Studies investigating physical therapy interventions in people with shoulder instability, and reporting selection criteria for shoulder instability were considered eligible. A narrative synthesis was conducted. RESULTS: Twenty-six studies were included. None reported using the FEDS classification as eligibility criteria for shoulder instability. Only 42% of the studies provided data of all four criteria of the FEDS classification. The most reported criterion was direction (92%), followed by etiology (85%), severity (65%), and frequency (58%). The most common reported descriptor for profiling shoulder instability was "dislocation" (83.3%), followed by "first-time" (66.7%), "anterior" (62.5%), and "traumatic" (59.1%). Regarding other instability classifications, only one study (4%) used the Thomas & Matsen classification, and two (8%) the Stanmore classification. CONCLUSIONS: The FEDS classification system has not been embraced enough by the physical therapy scientific community since its publication in 2011.
    • Artificial Intelligence ChatGPT’s Perspective on Implementation of Augmented Intelligence within Orthopaedic Practice—A Comparative Narrative Synthesis?

      Ashwood, Neil; Dekker, Andrew
      ChatGPT has obvious benefits in the way it can interrogate vast amounts of reference information and utilise metadata generation to answer questions posed to it and is freely available having been developed through human feedback. Already there are ethical and practical implications on its impact on learning and research. Artificial Intelligence (AI) has been seen as a way of improving healthcare provision by delivering more robust outcomes but measuring these and implementing AI within this setting is at present limited and disjointed. Methods: ChatGPT was interrogated to see what it felt were the barriers to its implementation within healthcare and in particular ortho paedic practice. The evidence for this determination was then examined for validity and applicability for a practical roll out at a Trust, Regional or Na tional level. Results: AI can synthesise a vast amount of information to help it answer specific questions. The context and structure of any question will de termine the usefulness of the answer which can then be used to develop prac tical solutions based on experience and resource limitations. Conclusions: AI has a role in service development and can quickly focus a working group to areas to consider when practically implementing change
    • The incidence and severity of diabetic hand infection presentations during the COVID-19 pandemic.

      Morris, H; Gillott, E.; Bainbridge, Chris; Johnson, Nick
      Diabetic hand infections are difficult to treat and can present with high morbidity. We set out to identify any changes in presentation and disease severity during the COVID-19 pandemic. A total of 61 pre-COVID and 32 during COVID patients with diabetes with a hand infection requiring intravenous antibiotics were included in the study. The pandemic caused a decrease in the number and proportion of presentations. Hospital admissions reduced as service provision was amended to enable increased outpatient treatment. However, there was a significant increase in surgical management (25 vs. 21, p = 0.02), total complications (5 vs. 8, p < 0.05) and incidence of amputations (2 vs. 4, p = 0.09). Mean haemoglobin A1C was also higher (48 mmol/L vs. 40 mmol/L, p < 0.05). While fewer patients attended the service during the pandemic, we witnessed an increased severity of hand infections in those we treated. There is a role for daily outpatient administration of intravenous antibiotics in selected patients to reduce the number of hospital admissions.
    • Systematic review of nerves at risk at the wrist in common surgical approaches to the forearm: Anatomical variations and surgical implications

      Ashwood, Neil
      Three commonly used approaches to the forearm in orthopedic surgery are Henry's, Thompson's, and the ulnar approach, each of which has the potential to cause injury to nerves around the wrist. Preserving these nerves is important to prevent complications such as neuroma formation and motor and sensory changes to the hand. We conducted a review of the literature to assess the nerves at risk and whether ‘safe zones’ exist to avoid these nerves. An independent reviewer conducted searches in Embase and MEDLINE of the literature from 2010 to 2020. A total of 68 papers were identified, with 18 articles being included in the review. Multiple nerves were identified as being at risk for each of the approaches described. In the anterior approach, the palmar cutaneous branch of the median nerve (PCBMN) is most at risk of injury. An incision immediately radial to the flexor carpi radialis (FCR) or directly over the FCR is most likely to avoid injury to both superficial branch of the radial nerve (SBRN) and PCBMN. With Thompson's approach, the safest zone for an incision is directly over or slightly radial to Lister's tubercle to avoid injury to SBRN and lateral cutaneous nerve of the forearm. For the ulnar approach, a safe zone was shown to be on the ulnar side of the wrist around the ulnar styloid (US) when the forearm was in supination or a neutral position to avoid injury to the dorsal branch of the ulna nerve (DBUN). Care must be taken around the US due to the density of nerves and the proximity of the last motor branch of the posterior interosseous nerve to the ulnar head. This review highlighted the proximity of nerves to the three most common surgical incisions used to access the forearm. In addition, anatomical variations may exist, and each of the nerves identified as being at risk has multiple branches. Both factors increase the potential of intraoperative damage if the anatomy is not properly understood. The surgeon must adhere carefully to the established approaches to the wrist and distal forearm to minimize damage to nerves and optimize surgical outcomes for the patient.
    • Day case orthopaedic trauma surgery effectiveness: a systematic review

      Ashwood, Neil
      Day case surgery facilitates effective orthopaedic care for ambulatory trauma cases and can act as an effective pathway in times of reduced resource availability within acute hospitals. A systematic review of the available literature was performed using a narrative synthesis to look for themes underpinning day case trauma practice. A 25 papers were selected from a total of 9956 papers screened to identify those papers that considered day case trauma surgery and its impact on clinical outcome, patient satisfaction and feasibility of delivery within the UK. 9014 patients had day case trauma operations within the 25 papers identified, 86% had general anaesthesia and 14% either regional or local anaesthesia. The mean reported age was 37.5 years with a wide age range (2-83) years treating roughly similar proportions of men and women with a high satisfaction rate when recorded. All areas of the upper limb were operated on apart from the scapula the commonest being the wrist. In the lower limb surgery was undertaken in the knee, ankle or foot with removal of foreign body or ankle fixation being the commonest procedures undertaken. Prevalence of complications at 0.0156% of cases undergoing day case surgery was seen to be lower than in a similar group of inpatient cases. resources are stretched. Day case surgery for trauma procedures within orthopaedics is safe, cost effective and well tolerated by patients. It frees up resources to facilitate treatment and should be utilised within each hospital to enable timely care.
    • Identifying clusters of objective functional impairment in patients with degenerative lumbar spinal disease using unsupervised learning.

      Klukowska, Anita
      OBJECTIVES: The five-repetition sit-to-stand (5R-STS) test was designed to capture objective functional impairment (OFI), and thus provides an adjunctive dimension in patient assessment. It is conceivable that there are different subsets of patients with OFI and degenerative lumbar disease. We aim to identify clusters of objectively functionally impaired individuals based on 5R-STS and unsupervised machine learning (ML). METHODS: Data from two prospective cohort studies on patients with surgery for degenerative lumbar disease and 5R-STS times of ≥ 10.5 s-indicating presence of OFI. K-means clustering-an unsupervised ML algorithm-was applied to identify clusters of OFI. Cluster hallmarks were then identified using descriptive and inferential statistical analyses. RESULTS: We included 173 patients (mean age [standard deviation]: 46.7 [12.7] years, 45% male) and identified three types of OFI. OFI Type 1 (57 pts., 32.9%), Type 2 (81 pts., 46.8%), and Type 3 (35 pts., 20.2%) exhibited mean 5R-STS test times of 14.0 (3.2), 14.5 (3.3), and 27.1 (4.4) seconds, respectively. The grades of OFI according to the validated baseline severity stratification of the 5R-STS increased significantly with each OFI type, as did extreme anxiety and depression symptoms, issues with mobility and daily activities. Types 1 and 2 are characterized by mild to moderate OFI-with female gender, lower body mass index, and less smokers as Type I hallmarks. CONCLUSIONS: Unsupervised learning techniques identified three distinct clusters of patients with OFI that may represent a more holistic clinical classification of patients with OFI than test-time stratifications alone, by accounting for individual patient characteristics.
    • Scoping review: Evidence for long-term follow-up and monitoring in shoulder and elbow arthroplasty

      Tambe, Amol
      AIMS: Long-term follow-up and monitoring of asymptomatic shoulder and elbow arthroplasty remains contentious, with a wide spectrum of non-evidence-based mechanisms used. This scoping review aims to outline related evidence, thereby informing research requirements. METHODS: Studies relevant to shoulder and elbow arthroplasty follow-up, surveillance and time-related failure were included. The review included randomised controlled trials, systematic reviews and economic studies indexed in MEDLINE, Embase, Cochrane CDSR and Cochrane CENTRAL since 1 January 2012. In addition, all registry studies, follow-up studies, cohort studies and case reports indexed in MEDLINE since 1 January 2020 were included. The screening was undertaken by two reviewers. Key characteristics of each study were described, alongside a narrative review. RESULTS: Twenty-one articles were included. We were unable to identify evidence that long-term follow-up and monitoring of asymptomatic shoulder and elbow arthroplasty identifies failure or leads to a revision that is of reduced patient morbidity and cost. In addition, no evidence was apparent to inform whether patients will self-present with a failing implant. Several surveillance mechanisms were identified. CONCLUSION: This scoping review highlights the paucity of evidence related to long-term follow-up and monitoring of shoulder and elbow arthroplasty, and the need for high-quality data to inform the development of evidence-based care pathways.
    • Physiotherapist-led exercise versus usual care (waiting-list) control for patients awaiting rotator cuff repair surgery: A pilot randomised controlled trial (POWER).

      Beckhelling, Jacqueline; Davis, Daniel; Pitt, Lisa
      BACKGROUND: Once a decision to undergo rotator cuff repair surgery is made, patients are placed on the waiting list. It can take weeks or months to receive surgery. There has been a call to move from waiting lists to 'preparation' lists to better prepare patients for surgery and to ensure it remains an appropriate treatment option for them. OBJECTIVE: To evaluate the feasibility, as measured by recruitment rates, treatment fidelity and follow-up rates, of a future multi-centre randomised controlled trial to compare the clinical and cost-effectiveness of undertaking a physiotherapist-led exercise programme while waiting for surgery versus usual care (waiting-list control). DESIGN: Two-arm, multi-centre pilot randomised controlled trial with feasibility objectives in six NHS hospitals in England. METHOD: Adults (n = 76) awaiting rotator cuff repair surgery were recruited and randomly allocated to a programme of physiotherapist-led exercise (n = 38) or usual care control (n = 38). RESULTS: Of 302 eligible patients, 76 (25%) were randomised. Of 38 participants randomised to physiotherapist-led exercise, 28 (74%) received the exercise programme as intended. 51/76 (67%) Shoulder Pain and Disability Index questionnaires were returned at 6-months. Of 76 participants, 32 had not received surgery after 6-months (42%). Of those 32, 20 were allocated to physiotherapist-led exercise; 12 to usual care control. CONCLUSIONS: A future multi-centre randomised controlled trial is feasible but would require planning for variable recruitment rates between sites, measures to improve treatment fidelity and opportunity for surgical exit, and optimisation of follow-up. A fully powered, randomised controlled trial is now needed to robustly inform clinical decision-making.
    • Comparison between intra-articular injections of corticosteroids, hyaluronic acid, PRP and placebo for thumb base osteoarthritis: A frequentist network meta-analysis.

      Johnson, Nick
      BACKGROUND AND AIMS: Current evidence for the use of intra-articular injections for thumb base osteoarthritis (TBOA) is equivocal. This study aims to investigate the efficacy of intra-articular corticosteroids, hyaluronic acid and platelet-rich plasma. METHODS: A Frequentist network meta-analysis was conducted comparing outcomes at short (≤3 months) and medium-term (>3-12 months) time points. RESULTS: Data from 7 RCTs and 1 non-RCT (446 patients) were collected, consisting of corticosteroids (n = 7), hyaluronic acid (n = 7), platelet-rich plasma (n = 2) and placebo (n = 2). At the short-term time point, no intra-articular injection demonstrated superiority over placebo at reducing pain. At the medium-term time point, superiority of platelet-rich plasma at reducing pain over placebo and corticosteroids was seen following sensitivity analysis (RCTs only) (SMD -1.48 95 % CI -2.71; -0.25). No injection proved superior at improving function at short or medium-term time points. CONCLUSIONS: Overall, despite the promising result for platelet-rich plasma, the evidence quality was limited to two studies only justifying the need for further and larger methodologically robust trials investigating corticosteroids, hyaluronic acid and platelet-rich plasma vs each other and placebo.
    • The Pathogenesis of Chiari Malformation and Syringomyelia: A Case Report and Systematic Review of Current Theories

      Ashwood, Neil
      We report a case of a 42-year-old female presenting with left axillary pain radiating down the arm and weakness in the ipsilateral hand. Specialist examinations of neurological and musculoskeletal systems were insignificant. Magnetic resonance imaging (MRI) of the whole spine and brain revealed cerebellar tonsillar herniation of 9-10mm indicating a Chiari type 1 malformation and a large tubular T2 high-intensity lesion in the cervical cord, extending from the C2/3-disc level down to C6/C7 as well as a similar but smaller lesion behind the bodies of C7 and T1. Both lesions were consistent with syringomyelia. Surgical intervention was deemed inappropriate, and she was treated with three months of physiotherapy. Regular follow-up for two years showed gradual symptom resolution, syrinx shrinkage, and no further complications arising secondary to Chiari type 1 malformation. Chiari malformation is an anatomical anomaly of the cranio-cervical junction. It is often incidentally found on MRI, but although asymptomatic in the population, complications associated with the condition such as syringomyelia are a common initial presentation. The relationship between Chiari malformation, particularly Chiari type 1 malformation, and syringomyelia is close with the majority of patients often presenting with idiopathic syringomyelia also found to have a Chiari type 1 malformation. Considerable discussion about the pathogenic mechanisms for syringomyelia development in Chiari malformation is recognized and advancing continually.
    • Does long-term follow-up and monitoring of primary shoulder arthroplasty identify failing implants requiring revision?

      Dover, Caroline; Walstow, Katherine; Pitt, Lisa; Morgan, Marie; Espag, Marius; Clark, David; Tambe, Amol
      BACKGROUND: Published scoping review has identified evidence paucity related to long-term follow-up of shoulder arthroplasty. We aim to report effectiveness of elective primary shoulder arthroplasty surveillance in identifying failing implants requiring revision. METHODS: Analysis of a prospective database recording shoulder arthroplasty and subsequent follow-up surveillance in a shoulder unit. Shoulder arthroplasty were performed by 4 fellowship-trained shoulder surgeons for accepted elective indications including the use of anatomic arthroplasty in arthritic shoulders with intact rotator cuff and a reverse prosthesis being utilized in rotator cuff deficient shoulders and rotator cuff competent arthritic shoulders when deemed preferable by the treating surgeon. All shoulder arthroplasty implants utilized had achieved a minimum 7A Orthopaedic Data Evaluation Panel (ODEP) rating. Included shoulder arthroplasty were performed 01/05/2004-31/12/2021 with minimum 1-year follow-up. Surveillance program involves specialist physiotherapist review at 1, 2, 3, 5, 8, 10, and 15-years postoperatively including clinical examination, outcome scoring and radiographs. Patient-initiated review occurred between timepoints if a patient requested assessment due to symptoms. Outcome measures include ratio of failing implants identified by surveillance and patient-initiated review, with number of surveillance reviews offered and proportion that identified a failing implant requiring revision calculated. RESULTS: 1002 elective primary shoulder arthroplasty with minimum 1-year follow-up were performed (547 reverse total shoulder arthroplasty [rTSA], 234 anatomic total shoulder arthroplasty [aTSA], 221 hemiarthroplasty [HA]). 238 patients died prior to 31/12/2022 resulting in 4019 surveillance appointments offered. 38 prostheses required revision ≥ 1-year postoperatively (6 rTSA, 9 aTSA, 23 HA) with surveillance identifying requirement in 53% (33% rTSA, 56% aTSA, 57% HA) and patient-initiated review in 47%. Mean years from implantation to revision was 5.2 (2.7 rTSA, 3.6 aTSA, 6.6 HA). Revision indications included rotator cuff failure (56% aTSR, 43% HA) and glenoid erosion (57% HA). CONCLUSION: This is the first series reporting effectiveness of shoulder arthroplasty surveillance in identifying implants requiring revision. Surveillance identified over half of implants requiring revision though only 0.5% of appointments identified revision requirement. Surveillance enrolment may influence patient-initiated review utilization therefore similar studies utilizing only patient-initiated follow-up would help inform recommendations.
    • The incidence and severity of diabetic hand infection presentations during the COVID-19 pandemic.

      Morris, H; Gillott, E.; Bainbridge, Chris; Johnson, Nicholas
      No abstract available.
    • Hip fractures in the older adult: orthopaedic and geriatric shared care model in Southland, New Zealand-a 5-year follow-up study.

      Morris, H
      BACKGROUND: Neck of femur fractures are common with associated high morbidity and mortality rates. National standards include provision of orthogeriatric care to any patient with a hip fracture. This study assessed the outcomes at 5 years following implementation of a collaborative orthogeriatric service at Southland Hospital in 2012. METHODS: Retrospective data were collected for patients aged 65 years and older admitted with a fragility hip fracture. Data were collated for 2011 (preimplementation) and 2017 (postimplementation). Demographic data and American Society of Anesthesiologists (ASA) scores were recorded to ensure comparability of the patient groups. Length of stay, postoperative complications and 30-day and 1-year mortality were assessed. RESULTS: 74 admissions with mean age at surgery of 84.2 years in 2011 and 107 admissions with mean age of 82.6 years in 2017. There was a higher proportion of ASA 2 and ASA 3 patients in 2017 compared with 2011 (p=0.036). The median length of stay in the orthopaedic ward was unchanged in the two cohorts but there was a shorter median length of stay by 6.5 days and mean length of stay by 11 days in 2017 in the rehabilitation ward (p<0.001 for both median and mean). Through logistic regression controlling for age, sex and ASA score, there was a reduction in the odds of having a complication by 12% (p<0.001). The study was too small to undertake statistical testing to calculate significant difference in overall 30-day and 1-year mortality between the groups. CONCLUSION: The orthogeriatric service has reduced the frequency of complications and length of stay on the rehabilitation ward 5 years following implementation.
    • To plate, or not to plate? A systematic review of functional outcomes and complications of plate fixation in patellar fractures.

      Ilo, Kevin
      PURPOSE: Poor outcomes and high complication and reoperation rates have been reported with tension-band wiring (TBW) in the management of patellar fractures and particularly the comminuted ones. The purpose of this study was to investigate the functional outcomes and complication rates of patellar fractures managed with open reduction and internal fixation (ORIF) with a plate. METHODS: MEDLINE, EMCare, CINAHL, AMED and HMIC were searched, and the PRISMA guidelines were followed. Two independent reviewers extracted the data from the included studies and assessed them for the risk of bias. RESULTS: Plating of patellar fractures is associated with satisfactory range of movement (ROM) and postoperative function and low pain levels. We found a 10.44% complication rate and a low reoperation rate. Reoperations were mainly performed for metalwork removal. CONCLUSION: ORIF with plating of patellar fractures is a safe alternative in the management of patellar fractures and may be associated with a lower complication and reoperation rate compared to TBW. Future randomized prospective studies are needed to validated the results of the present systematic review.
    • The Impact of Surgeon Speciality Interest on Outcomes of Emergency Laparotomy in IBD

      Tierney, Gillian; Bunce, J; Doleman, Brett; Lund, Jonathan
      Introduction Emergency laparotomy may be required in patients with inflammatory bowel disease (IBD). NELA is the largest prospectively maintained database of adult emergency laparotomies in England and Wales and includes clinical urgency of the cases. The impact of surgeon subspeciality on outcomes after emergency laparotomy for IBD is unclear. We have investigated this association, according to the degree of urgency in IBD emergency laparotomy, including the effect of minimally invasive surgery (MIS). Methods Adults with IBD in the NELA database between 2013 and 2016 were included. Surgeon subspeciality was colorectal or non-colorectal. Urgencies are ‘Immediate’, ‘2–6 h’, ‘6–18 h’ and ’18–24 h’. Logistic regression was used to investigate in-patient mortality and post-operative length of stay (LOS). Results There was significantly reduced mortality and LOS in IBD patients who were operated on by a colorectal surgeon in the least urgent category of emergency laparotomies; Mortality adjusted OR 2.99 (CI 1.2–7.8) P = 0.025, LOS IRR 1.18 (CI 1.02–1.4) P = 0.025. This association was not seen in more urgent categories. Colorectal surgeons were more likely to use MIS, P \0.001, and MIS was associated with decreased LOS in the least urgent cohort, P \0.001, but not in the other urgencies. Conclusions We found improved outcomes in the least urgent cohort of IBD emergency laparotomies when operated on by a colorectal surgeon in comparison to a non-colorectal general surgeon. In the most urgent cases, there was no benefit in the operation being performed by a colorectal surgeon. Further work on characterising IBD emergencies by urgency would be of value
    • Arthroscopic Capsular Shrinkage Is Safe and Effective in the Treatment of Midcarpal Instability in a Pediatric Population: A Single-Center Experience of 51 Cases.

      Wharton, RMH; Lindau, Tommy
      Objective  Treatment of palmar midcarpal instability (PMCI) remains controversial and children can develop PMCI from asymptomatic hypermobility. Recently, case series have been published regarding the use of arthroscopic thermal shrinkage of the capsule in adults. Reports of the use of the technique in children and adolescents are rare, and there are no published case series. Methods  In a tertiary hand centre for children's hand and wrist conditions, 51 patients were treated with arthroscopy for PMCI between 2014 and 2021. Eighteen out of 51 patients carried additional diagnosis of juvenile idiopathic arthritis (JIA) or a congenital arthritis. Data were collected including range of movement, visual analogue scale (VAS) at rest and with load, and grip strength. Data was used to determine the safety and efficacy of this treatment in paediatric and adolescent patients. Results  Mean follow-up was 11.9 months. The procedure was well tolerated and no complications were recorded. Range of movement was preserved postoperatively. In all groups VAS scores at rest and with load improved. Those who underwent arthroscopic capsular shrinkage (ACS) had significantly greater improvement in VAS with load, compared with those who underwent arthroscopic synovectomy alone ( p  = 0.04). Comparing those treated with underlying JIA versus those without, there was no difference in postoperative range of movement, but there was significantly greater improvement for the non-JIA group in terms of both VAS at rest ( p  = 0.02) and VAS with load ( p  = 0.02). Those with JIA and hypermobility stabilized postoperatively, and those with JIA with signs of early carpal collapse and no hypermobility achieved improved range of movement, in terms of flexion ( p  = 0.02), extension ( p  = 0.03), and radial deviation ( p  = 0.01). Conclusion  ACS is a well-tolerated, safe, and effective procedure for PMCI in children and adolescents. It improves pain and instability at rest and with load, and offers benefit over open synovectomy alone. This is the first case series describing the usefulness of the procedure in children and adolescents, and demonstrates effective use of the technique in experienced hands in a specialist centre. Level of Evidence  This is a Level IV study.
    • Artificial Intelligence; a Pragmatic Approach to Implementation in Medicine, a Review of the literature and a Survey of Local Practice in Midlands in UK

      Capes, Neil; Sarhan, Islam; Ashwood, Neil; Dekker, Andrew
      The use of Artificial Intelligence (AI) for clinical pathway management and decision making is believed to improve clinical care and has been used to improve pathways for treatment in most medical disciplines. Methods: A literature review was undertaken to identify the hurdles and steps required to introduce supported clinical decision-making using AI within hospitals. This was supported by a survey of local hospital practice within the Mid lands of the United Kingdom to see what systems had been introduced and were functioning effectively. Results: It is unclear how to practically im plement systems using AI within medicine easily. Algorithmic medicine based on a set of rules calculated from data only takes a clinician so far to deliver patient centred optimal treatment. AI facilitates a clinician’s ability to as similate data from disparate sources and can help with some of the analysis and decision making. However, learning remains organic and the subtleties of difference between patients, care providers who exhibit non-verbal commu nication for instance make it difficult for an AI to capture all the pertinent information required to make the correct clinical decision for any given individual. Hence it assists rather than controls any process in clinical practice. It also must continually renew and adapt considering changes in practise and trends as the goalposts change to meet fluctuations in re sources and workload. Precision surgery is benefiting from robotic-assisted surgery in parts driven by AI and being used in 80% of trusts locally. Con clusion: The use of AI in clinical practice remains patchy with it being adopted where research groups have studied a more effective method of How to cite this paper: Capes, N., Patel, H., Sarhan, I., Ashwood, N., Dekker, A. and Shehata, R. (2023) Artificial Intelligence; a Pragmatic Approach to Implementation in Medicine, a Review of the literature and a Survey of Local Practice in Midlands in UK. International Journal of Intelligence Science, 13, 63-79. Received: June 18, 2023 Accepted: July 24, 2023 Published: July 31, 2023 Copyright © 2023 by author(s) and Scientific Research Publishing Inc. This work is licensed under the Creative Commons Attribution International License (CC BY 4.0). Open Access N. Capes et al. DOI: 10.4236/ijis.2023.133005 64 International Journal of Intelligence Science monitoring or treatment. The use of robotic-assisted surgery on the other hand has been more rapid as the precision of treatment that this provides appears attractive in improving clinical care.
    • Strategies for fixation of periprosthetic fragility fractures of the neck of femur below a well-functioning hip resurfacing arthroplasty: A case-series

      Kerr, Nicholas; Quah, Conal; Lewis, James
      INTRODUCTION: Metal-on-metal Hip Resurfacing (HR) was performed in many young individuals as it conserved bone stock and had low wear rates, before it became less popular due to the detection of Adverse Reactions to Metal Debris. As such, many patients in the community have well-functioning HRs and as they age, the incidence of fragility fractures of the neck of femur around the existing implant is expected to increase. These fractures are amenable to surgical fixation as adequate bone stock remains in the head of the femur and the implants are well fixed. CASE-SERIES: We present a series of six cases which were treated by fixation using locked plates (3), dynamic hip screws (2) and cephalo-medullary nail (1). Four cases achieved clinical and radiographic union with good function. One case had a delayed union, though union was finally achieved at 23 months. One case had an early failure necessitating revision to a Total Hip Replacement after 6 weeks. DISCUSSION: We highlight the geometrical principles of placing fixation devices under an HR femoral component. We have also conducted a literature search and present details of all case reports to date. CONCLUSION: Fragility per-trochanteric fractures under a well-fixed HR with good baseline function are amenable to fixation using a variety of methods including large screw devices that are commonly used in this location. Locked plates including variable angle locking designs should be kept available if needed.
    • Daratumumab, bortezomib and dexamethasone at first relapse for patients with multiple myeloma: A real-world multicentre UK retrospective analysis

      Al-Kaisi, Firas
      Daratumumab, bortezomib and dexamethasone (DVd) is approved for patients with relapsed multiple myeloma following the CASTOR phase 3 clinical trial. This retrospective multicentre analysis assesses the overall response rate (ORR) and progression-free survival (PFS) in routine clinical practice for patients at first relapse treated with DVd incorporating weekly bortezomib. Data were collected from 296 sequential patients treated across 15 UK centres. After a median follow-up of 21 months, the ORR was 82% (26% partial response, 56% very good partial response or better) and the median PFS was 16 months [95% confidence interval (CI) 12-20 months]. Results were similar regardless of prior lenalidomide exposure. The median time to next treatment was 20 months (95% CI 15-25 months) and the estimated overall survival at two years was 74%. Patients with high-risk features (by cytogenetics, International Staging System or extramedullary disease) and those treated within 18 months of initiation of progression-free treatment, or within 12 months of autologous stem cell transplant, had significantly inferior outcomes. The grade 2 and 3 peripheral neuropathy rate was 7%. DVd with weekly bortezomib was effective in a heterogenous real-world population at first relapse with a low rate of peripheral neuropathy. However, high-risk patients had inferior outcomes and should be considered for alternative treatments.