Evaluation of the trajectory of recovery following surgically treated acetabular fractures

Aims

Acetabular fractures are associated with long-term morbidity. Our prospective cohort study sought to understand the recovery trajectory of this injury over five years.

Methods

Eligible patients at a level I trauma centre were recruited into a longitudinal registry of surgical acetabular fractures between June 2004 and August 2019. Patient-reported outcome measures (PROMs), including the 36-Item Short Form Health Survey (SF-36) physical component summary (PCS), were recorded at baseline pre-injury recall and six months, one year, two years, and five years postoperatively. Comparative analyses were performed for elementary and associated fracture patterns. The proportion of patients achieving minimal clinically important difference (MCID) was determined. The rate of, and time to, conversion to total hip arthroplasty (THA) was also established.

Results

We recruited 251 patients (253 fractures), with a 4:1 male to female ratio and mean age of 46.1 years (SD 16.4). Associated fracture patterns accounted for 56.5% of fractures (n = 143). Trajectory analysis showed all timepoints had significant disability versus baseline, including final follow-up (p < 0.001). Elementary fractures had higher SF-36 PCS at six months (p = 0.023) and one year (p = 0.007) compared to associated fractures, but not at two years (p = 0.135) or five years (p = 0.631). The MCID in SF-36 PCS was observed in 37.3% of patients (69/185) between six months and one year, 26.9% of patients (39/145) between one and two years, and 23.3% of patients (20/86) between two and five years, highlighting the long recovery potential of these injuries. A significant proportion of patients failed to attain the MCID after five years (38.1%; 40/105). Conversion to THA occurred in 13.1% of patients (11/110 elementary and 22/143 associated fractures). Approximately two-thirds of THAs (21/33 patients; 63.6%) were performed within two years of index surgery.

Conclusion

Acetabular fractures significantly impact physical function. Recovery trajectory is often elongated beyond one year, with two-thirds of our patients displaying persistent clinically relevant long-term disability.

Combined nail-plate constructs in the management of osteoporotic native distal femoral fractures: a systematic review of the available evidence

PURPOSE

Distal femoral fractures account for 4-6% of fragility fractures. These may be managed using a combined nail-plate construct (NPC). The use of NPCs is gaining traction. Whilst several theoretical advantages exist, there is little evidence reporting on binary or patient-reported outcomes. The aim of the current study was to perform a systematic review of the available literature pertaining to NPCs and their treatment of native distal femoral fractures, appraising the outcomes and focusing on the rationale for their increasing uptake in recent literature.

METHODS

A comprehensive search of MEDLINE, EMBASE, Clinical Key, PubMed and Cochrane library was performed from date of inception up to in August 9, 2022. All study languages were included initially. A further Google Scholar search review was performed to identify any other studies not identified in the database interrogation. Studies were eligible if they reported on the use of nail-plate constructs in managing distal femoral fractures. Any outcome metric was permitted. The study was conducted in accordance with PRISMA guidelines. Risk of bias was assessed using the Methodological Index for non-randomised Studies tool. Quantitative analysis was performed using a log odds ratio random effects model. The Knapp-Hartung adjustment was utilised if the total number of included studies was < 5. Study effect sizes and appropriate plots were constructed to illustrate the outcomes data.

RESULTS

A total of four studies were eligible for inclusion. Study data was extracted and summarised with their relevant outcomes presented. The literature review demonstrated that the use of NPCs led to significantly earlier full weight bearing (p < 0.001) and had reduced non-union rates over a single construct, without affecting infection rates (12.5% vs. 5.6%; p = 0.289) and significantly lower implant failure rates (10.5% vs. 0%; p = 0.011). A meta-analysis is performed of available studies and Forrest plots presented.

CONCLUSION

The use of NPC in the management of native osteoporotic DFFs is gaining traction but the available evidence is of low grade with significant heterogeneity in small cohorts of patients. We suggest that a large-scale, multicentre prospective study should be performed, with agreed functional and radiological outcome metrics, to provide a more robust evidence base.

Definitive Taylor Spatial Frame management for the treatment of high-energy open tibial fractures: Clinical and patient-reported outcomes

BACKGROUND

High energy open tibial fractures are complex injuries with no consensus on the optimal method of fixation. Treatment outcomes are often reported with union and re-operation rates, often without specific definitions being provided.  We sought to describe union, reoperation rates, and patient reported outcomes, using the validated EQ-VAS and Disability Rating Index (DRI) scores, following stabilisation with a Taylor Spatial Frame (TSF) and a combined orthoplastic approach for the management of soft tissues. A literature review is also provided.

METHOD

A prospective cross-sectional follow up of open tibial fractures, treated at a level 1 major trauma centre, managed with a TSF using a one ring per segment technique between January 2014 and December 2019 were identified. Demographic, injury and operative data were recorded, along with Patient Reported Outcome Measures (PROM) scores, specifically the EQ-VAS and Disability Rating Index (DRI). Union rates, defined by radiographic union scale in tibia (RUST) scores, and re-operation rates were recorded. Appropriate statistical analyses were performed, with a p<0.05 considered statistically significant.

RESULTS

Overall, 51 patients were included. Mean age was 51.2 ± 17.4 years, with a 4:1 male preponderance. Diaphyseal and distal fractures accounted for 76% of cases. Mean time in frame was 206.7 ± 149.4 days. Union was defined and was achieved in 41/51 (80.4%) patients. Deep infection occurred in 6/51 (11.8%) patients. Amputation was performed in 1 case (1.9%). Overall re-operation rate was 33%. Time to union were significantly longer if re-operation was required for any reason (uncomplicated 204±189 vs complicated 304±155 days; p = 0.0017) . EQ-VAS and DRI scores significantly deteriorated at 1 year follow-up (EQVAS 87.5 ± 11.7 vs 66.5 ± 20.4;p<0.0001 and DRI 11.9 ± 17.8 vs 39.3 ± 23.3;p<0.0001). At 1 year post op, 23/51(45.1%) required a walking aid, and 17/29 (58.6%) of those working pre-injury had returned to work.

CONCLUSION

Open tibial fracture have significant morbidity and long recovery periods as determined by EQVAS and DRI outcome measures.  We report the largest series of open tibial feature treated primarily with a TSF construct, which has similar outcomes to other techniques, and should therefore be considered as a useful technique for managing these injuries.

Targeted Temperature Management for Severe Subarachnoid Hemorrhage Using Endovascular and Surface Cooling Systems: A Nonrandomized Interventional Study Using Historical Control

BACKGROUND

Although targeted temperature management (TTM) may mitigate brain injury for severe subarachnoid hemorrhage (SAH), rebound fever correlates with poor outcomes.

OBJECTIVE

To study the effect of endovascular TTM after rewarming from initial surface cooling during a high-risk period for delayed cerebral ischemia.

METHODS

We studied patients with World Federation of Neurological Surgeons grade V SAH before and after the introduction of endovascular TTM. Both groups (36 patients each) were treated with TTM at 34 °C with conventional surface cooling immediately after SAH diagnosis, together with emergency aneurysm repair. When rewarmed to 36 °C, around 7 days later, the study group underwent TTM at 36 to 38 °C for 7 days with an endovascular cooling system. The control group was treated with antipyretics.

RESULTS

Sex, age, Glasgow Coma Scale score, modified Fisher computed tomography classification, aneurysm location, and treatment methods were not different between the study and control groups. Differences were detected in the incidence of fever >38 °C (13 vs 26 patients, P = .0021), duration of fever >38 °C (4.1 vs 18.8 hours, P = .0021), incidence of vasospasm-related cerebral infarction (17% vs 42%, P = .037), and the likelihood of excellent outcomes (0 and 1 on a modified Rankin Scale) at 6 months (42% vs 17%, P = .037). In endovascular TTM, shivering occurred more frequently in patients with better outcomes, requiring aggressive treatment to avoid fever.

CONCLUSION

Endovascular TTM at 36 to 38 °C after surface cooling was feasible and safely performed in patients with severe SAH. Combined TTM for 2 weeks was associated with a lower incidence of vasospasm-related infarction and may improve outcomes.

Weight and Abdominal Pressure-Induced Shunt Trouble in Patients With Shunted Normal Pressure Hydrocephalus: A Comprehensive Study on Pressure Environment of Shunt System

Objectives

We identified a new type of shunt malfunction (SM) in patients with normal pressure hydrocephalus (NPH). It is induced by weight change and can be treated with valve readjustment. There were two types of SM as follows: Underdrainage induced by the weight gain and overdrainage induced by the weight loss. This study aims to elucidate this mechanism by assessing the shunt pressure environment.

Methods

The total pressure environment of the shunt system was prospectively studied in patients with shunted NPH at Osaka Medical College Hospital from 1999 to 2005. We measured the pressure environment during the initial pressure setting of the valve by the intracranial pressure (ICP) guide, after setting the valve, and when SM was suspected. We evaluated ICP, intra-abdominal pressure (IAP), and hydrostatic and perfusion pressures of the shunt system in the sitting and supine positions. The target ICP for valve setting was empirically set at the range from −8 to −13 mm Hg in the sitting position, referring to the external auditory meatus. During the study period, we identified five cases of SM induced by weight change and assessed the changes in the pressure environment across pre-SM, SM, and post-SM.

Results

In four cases of underdrainage, gait disturbance worsened with an average weight gain of 6.8 ± 1.2 kg. With weight gain, IAP and ICP increased by 8.8 ± 1.6 and 4.8 ± 1.0 mm Hg, respectively. Consequently, ICP increased to −6.5 ± 1.9 mm Hg. One overdrainage patient developed an asymptomatic chronic subdural hematoma (CSDH) with a weight loss of 10 kg. With the weight loss, both IAP and ICP decreased by 5 mm Hg, and concomitantly, ICP decreased to −18 mm Hg. In all patients, the valve readjustment restored their ICP to the target pressure. After the valve readjustment, the gait disturbance improved immediately, and the CSDH disappeared after 1 month.

Conclusion

In patients with shunts, the weight change was linked to ICP via IAP. Due to the weight change, the underdrainage occurred when ICP was above the target pressure, and the overdrainage occurred when ICP was below it. We named this SM as the weight and abdominal pressure-induced shunt trouble. The patients with SM along with weight changes should be the first to be tried for the valve readjustment.

A Prospective Study Assessing Wound Complications in a Series of Foot and Ankle Patients Treated With Enoxaparin: A Baseline for Future Studies

Background and objective

Low-molecular-weight heparin (LMWH) prophylaxis has now become the gold-standard practice in patients requiring lower limb immobilization. We had noticed an increase in the incidence of wound-healing problems at our center, and the severity of the problems was found to be worse in patients undergoing foot and ankle surgery since we had adopted this practice. In this study, we aimed to describe the incidence and severity of wound-healing problems in this group of patients.

Methods

This was a prospective study and we collected data on the frequency and severity of wound problems occurring in patients undergoing a variety of foot and ankle operations. All patients underwent a standard agreed-on method of wound closure and dressings. Wounds were reviewed after two weeks and wound characteristics were noted using a rigid proforma. The primary outcome measure was to determine the incidence of delayed wound healing (DWH) and wound infections requiring antibiotics. Secondary outcomes were the characteristics of each delayed-healing wound.

Results

A total of 158 patients met the inclusion criteria of the study. One patient was not given postoperative LMWH and was excluded from the final analysis. Seven patients (4.5%) were noted to have DWH and four patients (2.6%) had a wound infection at the two-week postoperative follow-up. None of the patients required a second operation. Among patients with wound-healing problems, wound contour irregularities were noted in 51% and margin separation was noted in 65%.

Conclusion

The overall incidence of wound-healing problems such as DWH and wound infections was low in patients receiving prophylactic LMWH for foot and ankle surgery. Where postoperative wound problems did occur, these were associated with poor wound characteristics such as margin separation or contour irregularity. Further studies should be conducted to ascertain if the use of LMWH leads to problems with wound appearance.

Speeding through the pandemic: Perceptual and psychological factors associated with speeding during the COVID-19 stay-at-home period

During the COVID-19 stay-at-home period there were observed increases in both the percentage of cars engaged in extreme speeding, and the percentage of cars traveling below the speed limit. These changes have been attributed to unusually low traffic volume during the stay-at-home period. We develop a novel theoretical account, based on existing empirical research, of perceptual and psychological processes that may account for changes in speeding behavior under low traffic volume conditions. These include impaired ability to accurately perceive and control speed due to change in visual information, decreased salience of certain norms about socially appropriate speeds, lower perceived risk of speeding, and increased boredom leading to risk-taking behaviors. Further, we consider that individual attitude functions may account for the observed split in speeding behavior.

Radiographic analysis of Müller-Weiss disease

BACKGROUND

The only classification of Müller-Weiss disease (MWD) is based primarily on Méary's talo-first metatarsal angle. It describes increasing sag of the medial longitudinal arch with greater degrees of compression and fragmentation of the navicular. Purportedly, the talar head pushes the subtalar joint into varus and drives the medial pole of the navicular medially, as it protrudes inferiorly and laterally. Its authors stipulated heel varus as a pre-requisite, coining the term 'paradoxical pes planus varus' to define heel varus and flatfoot as hallmark deformities of the condition.

METHODS

We measured Méary's and Kite's talocalcaneal angles, heel offset, anteroposterior thickness of the navicular at each naviculocuneiform (NC) joint, medial extrusion of the navicular and calculated percentage compression at each NC joint in 68 consecutive feet presenting with MWD. Morphology and activity at the various peri-navicular joints were studied using SPECT-CT in 45 feet.

RESULTS

Inverse relationships between Méary's angle and degree of navicular compression reach statistical significance at NC2 but not at NC3. Strong correlation exists between medial extrusion and percentage compression at NC2 and NC3. Medial extrusion is significantly greater on the affected side in unilateral cases and on the more compressed side in bilateral cases. Significant inverse relationships exist between Kite's angle and percentage compression at both NC2 and NC3 and degree of medial extrusion of the navicular. No correlation was detected between Kite's angle and either heel offset or Méary's angle. Varus heel offset was present in only 33% of cases. The combination of heel varus and negative Méary's angle was present in just 26% of cases, the commonest combination being heel valgus with sagging at 56%.

CONCLUSION

Our findings confirm part of Maceira's hypothesized pathomechanism of MWD. Reductions in Kite's talocalcaneal angle confirm that lateral and inferior protrusion of the talar head causes increasing compression and medial extrusion of the navicular. However, such shift of the talar head does not always lead to heel varus. As such, we caution against universal advocacy of lateral displacement calcaneal osteotomy, as the heel is not always in varus in MWD.

Anticoagulation Protocol for Secondary Prevention of Acute Ischemic Stroke Associated with Nonvalvular Atrial Fibrillation

OBJECTIVES

There is no clear evidence regarding when to initiate oral anticoagulants (OACs) for secondary prevention of recurrent stroke in patients with atrial fibrillation (AF). Therefore, this study aimed to evaluate the safety and efficacy of a novel OAC initiation protocol for secondary prevention of acute ischemic stroke associated with AF.

MATERIALS AND METHODS

In this multicenter prospective study 597 consecutive Japanese patients with acute ischemic stroke associated with nonvalvular AF received post-stroke OACs according to a protocol based on severity (clinical (NIHSS) and radiological (ASPECTS + W)), rt-PA use, reperfusion, and hemorrhagic transformation (HT). Primary outcomes of safety and efficacy, including symptomatic hemorrhage, cerebral stroke, and disability were evaluated at 14 and 90 days.

RESULTS

Mean OAC initiation time was 2.60±2.14 days from onset. The shortest and longest mean initiation times were 0.47±0.50 and 6.16±0.72 days, respectively. Following OAC administration, no ICH was observed within 90 days. A significantly higher incidence of acute recurrent ischemic events occurred 14 days prior to OAC (4.7%) compared with chronic recurrence within 90 days (0.8%) (P = 0.00013, McNemar's test) . Recurrence prior to OAC use was significantly correlated with days to treatment (P = 0.00224), severity (NIHSS, ASPECTS+W: P = 0.0223, P = 0.0393, respectively), and HAS-BLED (P = 0.0395) and there were no correlations with CHADS₂ (P = 0.277) or CHA₂DS₂-VASc (P = 0.246) (Wilcoxon rank sum-test).

CONCLUSIONS

This comprehensive OAC initiation protocol was relatively safe and effective for secondary prevention of stroke in patients with AF. Risk of acute recurrence was high, indicating that OACs should be started as early as possible. (clinical trial registration number: 15B 128).

Preoperative Predictive Factors of Short-Term Outcome in Idiopathic Normal Pressure Hydrocephalus

BACKGROUND

Surgical treatment of idiopathic normal pressure hydrocephalus (iNPH) by ventriculoperitoneal (VP) or lumboperitoneal (LP) shunting can achieve long-term recovery of activities of daily living; however, in a subset of patients, maintenance of independence lasted for <6 months. This study examined positive preoperative predictive factors of short-term outcome for shunted iNPH patients.

METHODS

Over a 9-year period, consecutive patients from multiple centers diagnosed with probable iNPH underwent either VP or LP shunt surgery. Preoperative variables of age, symptom duration, iNPH severity, tap test response, and magnetic resonance imaging findings of disproportionately enlarged subarachnoid space hydrocephalus (DESH) or incomplete DESH were retrospectively evaluated in relation to 1-year postoperative outcome.

RESULTS

Outcome for 154 shunt patients (12 VP, 142 LP) as measured by postoperative disability modified Rankin Scale (mRS) and iNPH-gait disturbance (GD) was the same regardless of age. Symptom duration was inversely correlated with both iNPH severity (P < 0.0001) and postoperative improvement at 1 year (P = 0.0015). Severity also correlated inversely with postoperative improvement at 1 year (P < 0.0001). Age was not significantly correlated with the degree of postoperative improvement (mRS: P = 0.487; iNPH grading scale [GD]: P = 0.725). Outcome at 1 year (mRS, gait domain, and activities of daily living significantly improved in patients with a good response to the tap test (P < 0.0001) Preoperative DESH correlated with improvement in mRS and GD (P < 0.0001).

CONCLUSIONS

Mild preoperative iNPH severity, shorter preoperative symptom duration, good tap test response, and complete DESH were associated with good short-term postoperative outcome at 1 year. These positive factors may be useful for prediction of short-term surgical outcome in iNPH patients.

Are patient-reported outcomes the same following second-side surgery in primary hip and knee arthroplasty?

Aims

Up to one in five patients undergoing primary total hip (THA) and knee arthroplasty (TKA) require contralateral surgery. This is frequently performed as a staged procedure. This study aimed to determine if outcomes, as determined by the Oxford Hip Score (OHS) and Knee Score (OKS) differed following second-side surgery.

Methods

Over a five-year period all patients who underwent staged bilateral primary THA or TKA utilizing the same type of implants were studied. Eligible patients had both preoperative and one year Oxford scores and had their second procedure completed within a mean (2 SDs) of the primary surgery. Patient demographics, radiographs, and OHS and OKS were analyzed.

Results

A total of 236 patients met the inclusion criteria, of which 122 were THAs and 114 TKAs. The mean age was 66.5 years (SD 9.4), with a 2:1 female:male ratio. THAs showed similar significant improvements in outcomes following first- and second-side surgery, regardless of sex. In contrast for TKAs, although male patients demonstrated the same pattern as the THAs, female TKAs displayed significantly less improvement in both OKS and its pain component following second-side surgery.

Conclusion

Female patients undergoing second-side TKA showed less improvement in Oxford and pain scores compared to the first-side. This difference in outcome following second-side surgery did not apply to male patients undergoing TKA, or to either sex undergoing THA.

Cite this article: Bone Jt Open 2021;2(4):243–254.

Health-related quality of life of inpatients and outpatients with TB in rural Malawi

INTRODUCTION: Patients being treated for TB may suffer reductions in health-related quality of life (HRQoL). This study aims to assess the extent of such reductions and the trajectory of HRQoL over the course of treatment in rural Malawi.METHODS: We collected patient demographic and socioeconomic status, TB-related characteristics, and HRQoL data (i.e., EQ-5D and a visual analogue scale VAS) from adults (age ≥18 years) being treated for TB in 12 primary health centers and one hospital in rural Thyolo District, Malawi, from 2014 to 2016. Associations between HRQoL and patient characteristics were estimated using multivariable linear regression.RESULTS: Inpatients (n = 197) consistently showed lower median HRQoL scores and suffered more severe health impairments during hospitalization than outpatients (n = 156) (EQ5D and VAS: 0.79, 55 vs. 0.84, 70). Longer treatment duration was associated with higher HRQoL among outpatients (EQ5D: 0.034 increase per 2 months, 95%CI 0.012-0.057). We found no substantial associations between patients´ demographic and socioeconomic characteristics and HRQoL in this setting.CONCLUSION: HRQoL scores among patients receiving treatment for TB in rural Malawi differ by clinical setting and duration of treatment, with greater impairment among inpatients and those early in their treatment course.

Continuous amplitude-integrated electroencephalography for prognostication of cardiac arrest patients undergoing extracorporeal cardiopulmonary resuscitation with targeted temperature management

BACKGROUND

Extracorporeal cardiopulmonary resuscitation (ECPR) has been increasingly used for adult cardiac arrest (CA) patients refractory to conventional CPR. However, data on early prognosticators of neurological outcome are lacking.

METHODS

CA patients undergoing ECPR were prospectively monitored via amplitude-integrated EEG (aEEG). Targeted temperature management (TTM) was induced using an extracorporeal membrane oxygenation system. aEEG background patterns were classified into continuous normal voltage (CNV), discontinuous normal voltage (DNV), low voltage (LV), flat trace (FT), burst suppression (BS), and status epilepticus (SE). The Cerebral Performance Category (CPC) scale scores at hospital discharge and at 6 months after discharge were assessed, as was wakefulness after TTM. Good neurological outcome was defined as a CPC score of 1 or 2.

RESULTS

Twenty-two patients were studied. Six patients who showed CNV within 24 hours after arrival, including one with initial FT and two with initial LV, regained consciousness and had good neurological outcome except for one who died of haemorrhagic complication. Patients with persistent FT or BS at any time did not regain consciousness. Regarding 19 patients in whom aEEG data were obtained within 24 hours, CNV background predicted good outcome at 6 months with 100% sensitivity, 93% specificity, 83% positive predictive values, and 100% negative predictive values. All these indices were 100% concerning wakefulness after TTM.

CONCLUSION

aEEG monitoring was feasible and practical in adult CA patients undergoing ECPR and TTM. Evolution of aEEG background within 24 hours provides early accurate information for neurological prognostication.

Fluoroscopic-Guided Paramedian Approach for Lumbar Catheter Placement in Cerebrospinal Fluid Shunting: Assessment of Safety and Accuracy

BACKGROUND

Spinal catheter insertion in lumboperitoneal (LP) shunt surgery for idiopathic normal pressure hydrocephalus (iNPH) is frequently associated with technical difficulties especially in patients with obesity and elderly patients with vertebral deformities.

OBJECTIVE

To elucidate the accuracy and safety of image-guided spinal catheter placement using a paramedian approach (PMA).

METHODS

We retrospectively analyzed 39 consecutive iNPH patients treated by LP shunting with spinal catheter insertion via the PMA. The success rate of catheter placement and the number of changes in puncture location were evaluated. Accuracy of catheter insertion was assessed by measuring both vertical and horizontal deviations in the point of catheter dural penetration from the center of the interlaminar space.

RESULTS

The success rate of catheter placement was 100% (39/39). The difficulty rate for catheter insertion, measured by the number of changes in puncture location, was 2.6% (1/39). No bloody punctures or surgical infections were observed. Accuracy of catheter insertion, measured as the degree of deviation, was 0.5 ± 1.9 mm horizontally and 0.0 ± 2.4 mm vertically. The rates of minor complications, including caudal catheter insertion, transient low-pressure headache, and root pain, were 5.1% (2/39), 10.4% (4/39), and 0% (0/43), respectively. Subdural hematoma requiring surgical intervention occurred in 1 case (2.6%). During the mean follow-up period of 36 mo, spinal catheter rupture at the level of the spinous processes was not observed.

CONCLUSION

Fluoroscopic-guided spinal catheter placement via the PMA was safe, accurate, and reliable, even for use in geriatric and obese patients.

Elastic nail fixation versus plate fixation of paediatric femoral fractures in school age patients - A retrospective observational study

INTRODUCTION

The management of paediatric femoral fractures continues to spark debate in published literature, with poor quality evidence guiding current guidelines on the optimum treatment in children. Many centres report excellent results for both elastic intramedullary nailing and plate fixation of diaphyseal femoral fractures. This study aimed to investigate the outcomes of femoral fractures treated with elastic nail fixation versus those treated with plate fixation in a tertiary children's trauma unit, and discuss the advantages and disadvantages of each technique.

MATERIALS AND METHODS

A retrospective review of all femoral fractures undergoing fixation at a level one paeditric trauma and tertiary referral unit, between 1st April 2009 and 30th April 2017, was performed.Clinical notes and radiographs were reviewed to determine patient demographics and injury, operative and hospital stay data. Radiological union, defined as bridging callus present on at least three out of four cortices on orthogonal radiographs, was determined at 12 weeks. Outcomes were determined using the Flynn Criteria. Patients were followed up for a minimum of 2 years. Data was statistically analysed, and a p value < 0.05 was considered significant.

RESULTS

There were a total of 28 patients- 14 in each treatment group. Patients undergoing elastic nail fixation were significantly older than plate fixation (9.7 ± 1.9 Vs 7.7 ± 1.8; p = 0.008). A male preponderance was noted (21/28), with no difference between groups (10 Vs 11; p = 1.00). Plate fixation demonstrated a tendency towards shorter length of stay (6.3 ± 2.1 Vs 7.8 ± 3.0; p = 0.134), earlier radiological union at 12 weeks (14 Vs 10; p = 0.098), lower postoperative analgesia requirements (0.82 ± 0.45 Vs 1.12 ± 0.97; p = 0.200), and better outcomes, as determined by the Flynn criteria.

CONCLUSIONS

In the authors opinion, plate fixation is a safe, effective alternative to elastic nail fixation with equivocal outcomes as determined by the Flynn Criteria. Plate fixation may offer advantages in shorter length of stay, reduced postoperative pain and earlier weightbearing. Further large scale, prospective research is required to determine whether these are borne out in practice.

Risk factors for catastrophic costs associated with tuberculosis in rural South Africa

<sec> <title>SETTING</title> Fifty-five public clinics in northern South Africa. </sec> <sec> <title>OBJECTIVE</title> To estimate patient costs and identify the factors associated with catastrophic costs among individuals treated for tuberculosis (TB). </sec> <sec> <title>DESIGN</title> We performed cross-sectional interviews of consecutive patients at public clinics from October 2017 to January 2018. 'Catastrophic costs' were defined as costs totalling ≥20% of annual household income. For participants with no reported income, we considered scenarios where costs were considered non-catastrophic if 1) costs totalled <US$7.70 (ZAR100) or 2) a multidimensional poverty index was above a certain threshold. </sec> <sec> <title>RESULTS</title> Among 327 participants, the estimated mean TB episode costs were US$365 (95%CI 233-498): out-of-pocket costs comprised 58% of costs, wages lost due to health care-seeking represented 26%, and income reduction accounted for 16% of costs. Ninety (28%) participants experienced catastrophic costs, which were associated with clinic travel times of 60-90 min (adjusted prevalence ratio [aPR] 1.7, 95%CI 0.9-3.1), unemployment (aPR 2.0, 95%CI 1.0-4.0) and having fewer household members (aPR 0.6, 95%CI 0.3-1.0). </sec> <sec> <title>CONCLUSIONS</title> In rural South Africa, catastrophic costs from TB are common and associated with distance to clinics, unemployment, and household size. These findings can help tailor social protection programs and enhance service delivery to patients at greatest risk of experiencing financial hardship. </sec>.

Contacts of underserved tuberculosis patients have higher odds of TB disease in North West England: a cohort study

OBJECTIVE

To investigate the association between patients' social risk factors and the risk of tuberculous infection and TB disease among their contacts in England.

DESIGN

This was a cohort study of all TB cases from North West England diagnosed between 27 March 2012 and 28 June 2016. The social risk factors of TB cases were evaluated to estimate their need for enhanced case management (ECM), from 0 (standard of care) to 3 (intensive social support).

RESULTS

A total of 2139 cases and their 10 019 contacts met the eligibility criteria. Being a contact of a patient with smear-positive TB with high ECM or being of Black Caribbean ethnicity was independently associated with greater odds of active TB disease (smear-positive vs. smear-negative, OR 5.3, 95%CI 3.2-8.7; ECM-3 vs. ECM-0, OR 2.2, 95%CI 1.01-5.0; Black Caribbean vs. White, OR 7.4, 95%CI 2.1-25). Being a contact of a patient with smear-positive TB or of Black Caribbean ethnicity was also independently associated with greater odds of tuberculous infection (smear-positive vs. smear-negative, OR 5.3, 95%CI 3.8-7.3; and Black Caribbean vs. White, OR 6.7, 95%CI 2.0-25).

CONCLUSIONS

The social complexity and ethnicity of patients were associated with tuberculous infection and TB disease in their contacts.

Tuberculosis patients with higher levels of poverty face equal or greater costs of illness

SETTING: Fifty-six public clinics in Limpopo Province, South Africa.OBJECTIVE: To evaluate the association between tuberculosis (TB) patient costs and poverty as measured by a multidimensional poverty index.DESIGN: We performed cross-sectional interviews of consecutive patients with TB. TB episode costs were estimated from self-reported income, travel costs, and care-seeking time. Poverty was assessed using the South African Multidimensional Poverty Index (SAMPI) deprivation score (a 12-item household-level index), with higher scores indicating greater poverty. We used multivariable linear regression to adjust for age, sex, human immunodeficiency virus status and travel time.RESULTS: Among 323 participants, 108 (33%) were 'deprived' (deprivation score >0.33). For each 0.1-unit increase in deprivation score, absolute TB episode costs were 1.11 times greater (95%CI 0.97-1.26). TB episode costs were 1.19 times greater with each quintile of higher deprivation score (95%CI 1.00-1.40), but lower by a factor of 0.54 with each quintile of lower self-reported income (higher poverty, 95%CI 0.46-0.62).CONCLUSION: Individuals experiencing multidimensional poverty and the cost of tuberculosis illness in Limpopo, South Africa faced equal or higher costs of TB than non-impoverished patients. Individuals with lower self-reported income experienced higher costs as a proportion of household income but lower absolute costs. Targeted interventions are needed to reduce the economic burden of TB on patients with multidimensional poverty.

Temporal changes in slipped upper femoral epiphysis at a regional level: a declining incidence and literature review

PURPOSE

Slipped upper femoral epiphysis (SUFE) is one of the most common adolescent hip pathologies in children with potential for life-long morbidity secondary to avascular necrosis (AVN). The primary aim is to determine an up-to-date demographic of SUFE, as well as current trends in presentation and radiological characteristics. Secondary aims are to quantify prophylactic fixation and subsequent contralateral SUFE.

METHODS

Between 01 January 2013 and 31 December 2015, all cases of SUFE were identified in Northern Ireland. Patient demographics, slip characteristics and outcomes are presented and the incidence rates were calculated using census data. Temporal changes in incidence, compared with a previous cohort, are demonstrated.

RESULTS

A total of 56 patients (80 hips) were identified. Based on census data, SUFE incidence has declined from 7.14 to 4.69/100,000 population aged < 16 years. Male cases predominated by > 2:1 ratio, and tended to be older than female cases. Approximately 75% of patients were above the 75th centile for age-sex adjusted body weight. Knee pain as a presenting symptom led to a delay in diagnosis. Prophylactic fixation was performed in 25.9%, with contralateral slips occurring in 27.5%. AVN occurred in 7.4% and remained static.

CONCLUSION

The incidence of SUFE has declined ~34% in our region. When SUFE occurs, knee pain often results in a delay in definitive diagnosis, and commands clinical vigilance to avoid delays in diagnosis. Patients in our region should be aware of a 1-in-4 contralateral slip rate. Overall, AVN rates remain static and are acceptable, despite the declining incidence of SUFE.

LEVEL OF EVIDENCE

Level III - Retrospective Cohort Study.

Outcomes and predictors of mortality following periprosthethic proximal femoral fractures

BACKGROUND

Periprosthetic fractures are a well-documented, serious complication of joint arthroplasty, occurring in up to 11% of hip replacements. We examined periprosthetic femoral fractures over an 8 year period to determine the demographics, fracture pattern and management options and associated outcomes. Furthermore, we sought to determine which comorbidities resulted in increased risk of 12 month mortality after periprosthetic fractures about hip replacements Methods: A retrospective review of a prospective fracture database was conducted for the years 2007-2015. The Fracture Outcomes Research Database (FORD) was interrogated for patients aged >60 years, admitted with periprosthetic hip fracture. Radiographic and Electronic Clinical Record review was performed to classify fractures, record treatments, comorbidies and 12 month mortality. A multivariate analysis was performed to determine comorbidities that significantly increased the risk of 12 month mortality.

RESULTS

A total of 189 patients were identified. The majority were Vancouver B1 fractures (61.9%); the operations were primarily cable plating (75.1%), with a smaller number of revision arthroplasties (21.2%) and only three proximal femoral replacement (1.6%). Four patients (2.1%) died before surgery. Only 27.3% returned to their usual residence post-discharge. Overall 30-day mortality was 2.1%, and one-year mortality was 11.6%. Patients who died tended to be older. In the multivariate analysis, ASA grade III/IV and active neoplasia were significant contributors to 12 month mortality.

CONCLUSION(S)

Our 12 month mortality (11.6%) is at the lower end of existing reported literature, and serves as a benchmark for UK practice. In the multivariate analysis, only ASA grade III/IV and an active neoplastic process were significantly associated with increased risk of mortality. Whilst large, multicenter trials, utilizing standardized treatment techniques are required to fully assess risk factors for 12-month mortality, it appears that those at significant risk are elderly, frail individuals with an active malignancy.

Percutaneous Arthroscopic-assisted Glenoid Fixation: A Novel Surgical Technique

Introduction

Scapular fractures are rare injuries and are often an indicator of high-energy trauma. These injuries are rare, and many are managed without surgery. The caveat to this is intra-articular extension into the glenoid when AO Foundation principles of fracture fixation for intra-articular injuries must be adhered to. We report a percutaneous arthroscopically assisted technique for fixation of a scapular fracture with extension into the glenoid fossa in a young male patient.

Case Report

A 22-year-old Caucasian male presented to the emergency department after a road traffic collision. Primary assessment and secondary surgery demonstrated an isolated shoulder injury involving the glenoid. Three-dimensional imaging was performed and revealed an intra-articular glenoid fracture with the involvement of the superior suspensory apparatus of the shoulder, not fitting into known classification systems. He underwent an arthroscopically assisted percutaneous screw fixation, which resulted in reduction of the suspensory apparatus and the glenoid fossa.

Conclusion

Intra-articular glenoid involvement in scapular fractures mandates anatomical reduction through internal fixation. We highlight that this technique is of benefit in these injuries and is easy and quick to perform. Validated outcomes, in this case, have been excellent, with no adverse events.

Heparin-induced Thrombocytopenia and the Use of r-Hirudin during Cardiopulmonary Bypass

We report the successful use of r-hirudin (lepirudin) for cardiopulmonary bypass in a 67-year-old man who developed heparin-induced thrombocytopenia type II during heparin treatment of an extensive deep venous thrombosis. Lepirudin was monitored by the modified ecarin clotting time in a “mobile laboratory” set up next to the cardiac theatre, aiming for lepirudin levels of 3.5 to 4.5 μg/ml during bypass.

Total Knee Arthroplasty in Severe Valgus Deformity Using a Modified Technique-A 10-Year Follow-Up Study

BACKGROUND

Valgus knee deformity accounts for only 10% of total knee arthroplasties (TKAs), but is frequently considered the most challenging to manage. This study provides a 10-year follow-up on a previously reported series of severe valgus knees performed using an unconstrained mobile-bearing TKA with a modified technique to validate this technique.

METHODS

A consecutive series of 275 predominantly cementless TKAs in 262 patients were performed for severe valgus (≥10°) deformity and prospectively followed to 10 years. Patient-reported outcome measures included the Oxford Knee Score, American Knee Society Score, Bartlett Patellar Score, and the Short Form 12 questionnaire.

RESULTS

Average valgus deformity was reduced from 15.6° to 3.8° (P < .001). At a mean follow-up of 10.4 years (range, 9.5-14.1), 90 (34.4%) patients had died. Of the reviewed survivors, the mean Oxford Knee Score was 27.8 ± 9.8, with an American Knee Society clinical score of 85.6 ± 17.0 and a functional score of 65.1 ± 20.4, with 78% of patients reporting good to excellent results. To date, there has been 1 (0.36%) revision and 13 (4.73%) reoperations. Kaplan-Meier implant survival was 99.6% at 10 years.

CONCLUSION

Despite its challenging nature, the valgus knee is associated with excellent survivorship and satisfactory long-term results using this modified technique.

LEVEL OF EVIDENCE

Level IV.

Postdischarge Unscheduled Care Burden After Lower Limb Arthroplasty

BACKGROUND

In contrast to postdischarge arthroplasty readmission rates, the unscheduled reattendance burden to primary care is under-reported. Understanding reasons for reattendance would allow for implementation of strategies to reduce this burden. The present study aims to quantify the out-of-hours (OOH) general practitioner and emergency department (ED) service reattendance burden and readmission rate after primary total hip arthroplasty and total knee arthroplasty, with estimation of the associated costs.

METHODS

This is a prospective consecutive cohort study. A prospective audit of all total hip arthroplasty and total knee arthroplasty patients in 2016 in a single high-volume UK arthroplasty unit was performed. Incidence and reasons for reattendance to OOH and ED service, as well as readmission rates, at both 30 and 90 days following discharge are reported. A multivariate analysis was performed to determine patient characteristics, which results in increased reattendance and readmission rates.

RESULTS

A total of 2351 procedures resulted in 374 attendances of OOH service and 665 to ED with a total estimated cost of £190,000 within 90 days. The readmission rate was 6.8%. Risk factors for reattendance and readmission were increasing age and a prolonged length of stay. The use of a 5-day postdischarge phone call and a dedicated Arthroplasty Care Practitioner favors reduced reattendances but not the readmission rate, with the additional benefit of being cost-effective.

CONCLUSION

The postdischarge arthroplasty reattendance burden is associated with significant costs, and strategies to reduce this should be developed. Further research is required to assess the effectiveness and cost-effectiveness of multicomponent strategies to reduce reattendance operating at scale.

Acute Kidney Injury After Prophylactic Cefuroxime and Gentamicin in Patients Undergoing Primary Hip and Knee Arthroplasty-A Propensity Score-Matched Study

BACKGROUND

Perioperative acute kidney injury (AKI) can be associated with lower limb arthroplasty and increases morbidity, length of stay, and mortality. AKI is more prevalent in some antibiotic regimes compared with others. The aim of the present study is to assess the impact of cefuroxime (CEF), with or without gentamicin (±G), on AKI rates.

METHODS

A prospective cohort study involving patients undergoing hip or knee arthroplasty was performed, between September 1, 2015 and November 30, 2016. Prophylactic intravenous antibiotics were administered according to local policy. AKI was graded according to the validated Acute Kidney Injury Network criteria based on the changes from baseline serum creatinine values. Propensity score matching was performed to identify risk factors. The local audit department approved the study. Appropriate statistical analyses were performed.

RESULTS

A total of 2560 met the inclusion criteria, with a female preponderance (1447/2560; 56.5%). The mean age was 67.5 ± 10.7 years, with males being significantly younger (65.9 ± 10.9 vs 68.7 ± 10.4 years). AKI developed in 32 cases (1.25%). There was no difference in AKI rates between CEF alone and CEF in combination with gentamicin (1.07% vs 1.36%; P = .524). Overall 31/32 cases were Acute Kidney Injury Network stage I. AKI did not affect the length of stay. Postoperative infection rate was 7/2560 (0.27%). There were no incidences of Clostridium difficile-associated diarrhea. Multivariate analysis demonstrated an increased AKI risk with the use of intravenous gentamicin.

CONCLUSION

C ± G yields low rates of infection and AKI compared with high-dose penicillin-based regimes. It is a safe and effective choice for lower limb arthroplasty.

The lateral malleolar bony fleck classified by size and pathoanatomy: The IOFAS classification

BACKGROUND

This study analyzes position of the peroneal tendons and status of the superior peroneal retinaculum (SPR) whenever a lateral malleolar bony flake fracture occurs.

METHODS

Twenty-four patients had a lateral malleolar bony fleck on anteroposterior ankle radiographs, either in isolation or associated with other hindfoot injuries. We studied size of the bony flecks, presence or absence of peroneal tendon dislocation and pathoanatomy on CT scans.

RESULTS

In 11 patients, a small bony fleck lies within the superior peroneal retinaculum and contiguous periosteum, which are stripped off the lateral fibula (Class II lesions). Tendons dislocate into the subperiosteal pouch thus formed, resembling Class I lesions without associated bony avulsion. Treatment for Class II is same as for Class I injuries. In 8 patients with a big bony fleck, tendons dislocate into the fracture site and SPR is intact (Class III lesions). In Class IV lesions, observed in 5 patients with 2-part calcaneal fracture/dislocation, SPR remains intact and peroneal tendons are not dislocated. The invariably large fleck results from the displacing lateral calcaneal fragment abutting against the fibula, whereas the dislocating tendons cause the bony avulsions in Classes II and III.

CONCLUSIONS

Due to pathoanatomical differences, surgical approach and natural history of neglected lesions differ depending on size of the bony fleck. The SPR must not be incised in case of big Class III flecks.

Synthetic versus autologous reconstruction (Syn-VAR) of the medial patellofemoral ligament: a study protocol for a randomised controlled trial

Background

Recurrent patellar instability incidence is 5.8/100,000 population, and recurrent dislocations are reported in the range of 15–80%. Recurrent instability is multifactorial and can be associated with disorder of limb alignment, osseous development, congruity of the patella in the trochlea and soft tissue static and dynamic constraints. The multifactorial aetiology makes management challenging, and a lack studies in a heterogeneous population with robust clinical outcomes compounds this further. The options for medial patellofemoral ligament (MPFL) reconstruction include autologous graft reconstruction with semitendinosus tendon, or synthetic polyester woven grafts. In theory, in the young active patient, the surgeon may wish to preserve the hamstring tendons to reduce postoperative morbidity to the patient, reduce delay in recovery from donor site morbidity and preserve the hamstring tendons. There have been no randomised controlled trials (RCTs) to date that directly compare autologous hamstring and synthetic reconstruction methods. This trial aims to assess the functional outcomes in those undergoing MPFL reconstruction with either autologous hamstring graft reconstruction, or a commercially available synthetic polyester open woven tape.

Methods

Following a power calculation using previous studies as the pilot data, a total of 30 patients will be included in the study. Enrolment is based upon strict inclusion/exclusion criteria outlined in the “Methods”. Participants will be randomized to receive either autograft or synthetic graft reconstruction. We aim to recruit 15 patients to each arm of the study. Surgery is performed by a single consultant surgeon experienced in both reconstructive options, using the default surgical technique for each. A postoperative physiotherapist-directed rehabilitation protocol will be implemented, as is routine. The primary outcome is the Kujala functional score and its change over the study period. Data on further secondary outcomes using validated outcomes scores will also be collected, specifically the Tegner and Lysholm, Banff Patellar Instability Index, and ACL Quality of Life Score. Secondary outcomes are complications and revision for any reason. The patient follow-up time is 2 years. The first patient will be recruited in January 2018. The expected trial deadline for recruitment is December 2018, with records and results being held for 5 years.

Discussion

This RCT study is the first to directly compare the efficacy of autograft versus synthetic allograft in MPFL reconstruction and the graft effects on patient-reported clinical outcomes.

Trial registration

ISRCTN, 16657952. Registered on 3 March 2017.

The study protocol has been approved by the Office for Research Ethics Committees of Northern Ireland (ORECNI 17/NI/0129).

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2622-7) contains supplementary material, which is available to authorized users.

An Assessment of the Representativeness of the SSI DA&A Study Panels

In this study, we used data derived from SSA administrative records to compare the composition of study panels, study samples, and the national population of former recipients of Supplemental Security Income (SSI) for drug addiction and alcoholism (DA&A). We found that the panels represented the selected samples in the nine-study sites in terms of demographics, SSI program status, and medical eligibility. However, the selected samples varied in how well they represented their target populations. Additionally, compared with the national DA&A population, SSI Study respondents were more likely to be black, to abuse both drugs and alcohol, to be more concentrated in the 30-49 age range, and to have been medically eligible for SSI in January and June 1997. Thus while the SSI Study data can be used to draw inferences about former DA&A SSI-only recipients in the study catchment areas, results should not be assumed to apply to the national population of such recipients.

Impact of scientific and technological advances

Advancements in research and technology are transforming our world. The dental profession is changing too, in the light of scientific discoveries that are advancing biological technology-from new biomaterials to unravelling the genetic make-up of the human being. As health professionals, we embrace a model of continuous quality improvement and lifelong learning. Our pedagogical approach to incorporating the plethora of scientific-technological advancements calls for us to shift our paradigm from emphasis on skill acquisition to knowledge application. The 2017 ADEE/ADEA workshop provided a forum to explore and discuss strategies to ensure faculty, students and, ultimately, patients are best positioned to exploit the opportunities that arise from integrating new technological advances and research outcomes. Participants discussed methods of incorporating the impact of new technologies and research findings into the education of our dental students. This report serves as a signpost of the way forward and how to promote incorporation of research and technology advances and lifelong learning into the dental education curriculum.

Early Management of Laryngeal Injuries

The results of acute laryngeal trauma sustained by 44 patients are reported. Three major aetiological groups are identified: road traffic accidents, blunt injury and penetrating injury. Road traffic accidents appear to produce severe injury, but the long-term follow-up results are similar to those laryngeal injuries which were not recognized initially and who developed a chronic stenosis. The blunt injury group sustained less forceful trauma; 14 of the 18 were treated conservatively and all patients had a good result. The majority of the penetrating injury group developed good breathing and a good voice following operation. Some of the technical expertise normally used to treat chronic laryngeal stenosis has been included in this series to good effect.

Catastrophic ceramic liner failure-The subtle signs of a non-engaged ceramic liner

Ceramic earrings have an established and successful history in total hip replacement. Occasionally, these articulations have problems, which include squeaking and implant fracture.

Intermittent gait disturbance in idiopathic normal pressure hydrocephalus

OBJECTIVES

We identified intermittent gait disturbance (IGD) observed in the mild stage of idiopathic normal pressure hydrocephalus (iNPH). The first purpose of this study was to clarify the temporal gait profile of IGD during long-distance gait. The second purpose was to confirm the difference in treatment effect after cerebrospinal fluid (CSF) shunting in patients with and without IGD.

MATERIALS AND METHODS

Fourteen consecutive iNPH patients with mild gait disturbance with a timed up-and-go (TUG) of <20 seconds were prospectively enrolled in the study. All patients were asked "Do you experience gait difficulty after over five minutes of walking?" Seven "yes" patients formed the IGD group, and seven "no" patients formed the persistent gait disturbance (PGD) group. One day before and 7 days after CSF shunting, gait function was evaluated by the 6-minute walk test (6MWT) and TUG.

RESULTS

Preoperatively, all patients in the IGD group demonstrated features of IGD during the 6MWT, characterized by a progressive pattern of decreased gait speed and step length with increased cadence and absence of leg pain. Post-operatively, these features of IGD improved in all patients. In the PGD group, preoperative walking did not significantly worsen during the 6MWT and did not significantly change 7 days after treatment. Improvement of gait symptoms 1 week after CSF shunting could be detected with 6MWT instead of TUG.

CONCLUSIONS

Intermittent gait disturbance is not a rare symptom in mild stage of iNPH and may serve as an important clinical diagnostic marker for identifying mild iNPH patients.

Biomedical Data Mining

Objective: To introduce the special topic of Methods of Information in Medicine on data mining in biomedicine, with selected papers from two workshops on Intelligent Data Analysis in bioMedicine (IDAMAP) held in Verona (2006) and Amsterdam (2007).

Methods: Defining the field of biomedical data mining. Characterizing current developments and challenges for researchers in the field. Reporting on current and future activities of IMIA’s working group on Intelligent Data Analysis and Data Mining. Describing the content of the selected papers in this special topic.

Results and Conclusions: In the biomedical field, data mining methods are used to develop clinical diagnostic and prognostic systems, to interpret biomedical signal and image data, to discover knowledge from biological and clinical databases, and in biosurveillance and anomaly detection applications. The main challenges for the field are i) dealing with very large search spaces in a both computationally efficient and statistically valid manner, ii) incorporating and utilizing medical and biological background knowledge in the data analysis process, iii) reasoning with time-oriented data and temporal abstraction, and iv) developing end-user tools for interactive presentation, interpretation, and analysis of large datasets.

Neurenteric cyst of the conus medullaris

Background:

Neurenteric cysts (NECs) are rare developmental malformations of the central nervous system (CNS) which originate as benign congenital lesions. They originate from developmental foregut precursors, and are presumed to be the result of abnormal partitioning of the embryonic notochord plate. Such NECs predominantly arise in the cervical region in patients around 6 years of age or in their twenties or thirties. Notably, NECs of the conus medullaris are exceedingly rare, especially in patients of advanced age.

Case Description:

A 70-year-old male presented with bilateral upper thigh and leg pain of over 20 years duration. His pain worsened over the past 3 years, and he sought surgical management. Although his neurological exam was normal, the lumbar magnetic resonance imaging revealed an intradural, nonenhancing, thin-walled, cystic lesion at L1/conus medullaris. The lesion was successfully resected without any adverse sequelae.

Conclusions:

NECs are rare congenital legions that involve the spine. Here, an L1 intradural extramedullay neuroenteric cyst of the conus medullaris was resected without complications.

A review of atypical subtrochanteric femoral fractures in Northern Ireland between 2010 and 2014

The term atypical femoral fractures most commonly occur in the subtrochanteric area. Concerns exist regarding the role of bisphosphonate treatment in their aetiology. Which surgical intervention provides the best outcome remains contentious. We reviewed all atypical subtrochanteric femoral fractures treated in Northern Ireland over 5 years, specifically investigating incidence, prodromal symptoms, association with bisphosphonates and optimal fixation methods. All subtrochanteric fractures treated in the region were identified and reviewed for atypical features. Case notes and imaging were then reviewed for each patient. A total of 364 subtrochanteric femoral fractures were identified during the 5-year study period. Twenty-six of these met the criteria for an atypical fracture (7%). Thirteen patients (50%) had presented with prodromal symptoms prior to complete fracture, six of which had radiological evidence of an incomplete fracture of the lateral cortex. Thirteen patients had a history of bisphosphonate treatment. All were treated operatively, with twenty-five cephalomedullary nails and one dynamic hip screw. Twenty-one patients had follow-up for greater than 2 months, nine of which (42.9%) achieved radiological union with a mean time to union of 297 days. Dynamically locked nails had a higher union rate than statically locked (80% versus 33.3%). Four patients required major revision surgery (15.4%). The quality of reduction was statistically significant in predicting need for revision. Atypical fractures often present with prodromal symptoms. Complete fractures are difficult to successfully manage with longer than expected times to union. Treatment with a dynamically locked, cephalomedullary with a good reduction provided the best results.

Managing extremely distal periprosthetic femoral supracondylar fractures of total knee replacements - a new PHILOS-ophy

We report two cases where a proximal humeral locking plate was used for the fixation of an extremely distal, type III peri-prosthetic femoral fractures in relation to a total knee replacement (TKR). In each case there was concern regarding the fixation that could be achieved using the available anatomic distal femoral plates due to the size and bone quality of distal fragment. The design of the Proximal Humeral Internal Locking System (PHILOS) allows nine 3.5-mm locking screws to be placed over a small area in multiple directions. This allowed a greater number of fixation points to be achieved in the distal fragment. Clinical and radiological short-term follow-up (6-12 mo) has been satisfactory in both cases with no complications. We suggest the use of this implant for extremely distal femoral fractures arising in relation to the femoral component of a TKR.

Fatigue failure of the cephalomedullary nail: revision options, outcomes and review of the literature

Cephalomedullary nail (CMN) failure is a rare entity following hip fracture treatment. However, it poses significant challenges for revision surgery, both mechanically and biologically. Nail failure rates have been reported at < 2%; however, no published studies have reported revision surgery procedures and their respective outcomes. We present a regional experience, with outcomes, of the revision options. We identified 20 fatigued CMNs that underwent four different revision procedures. Mean age was 73 ± 15.24 years, with a 3:1 female preponderance, and a median ASA grade of 3. Post-operative CMN radiographs demonstrated a significant number of fractures were fixed in varus, with reductions in neck-shaft angles post-operatively. A "poor" quality of reduction resulted in significantly earlier nail failure, compared to "adequate" and "good" (p = 0.027). Tip-Apex Distance (TAD) mean was 23.2 ± 8.3 mm, and an adequate TAD with three-point fixation was seen in only 35% of cases. Mean time to failure was 401.0 ± 237.2 days, with mean age at failure of 74.0 ± 14.8 years. Options after failure included revision CMN nail, proximal femoral locking plate (PFLP), long-stem or restoration arthroplasty, or femoral endoprosthesis. Barthel Functional Index scores showed no significant difference at 3 and 12 months post-operatively, nor any difference between treatment groups. Mean 12-month mortality was 30%, akin to a primary hip fracture mortality risk according to NICE guidelines. Mortality rates were lowest in revision nails. Subsequent revision rates were higher in the PFLP group. There is no reported evidence on the best surgical technique for managing the failed CMN, with no clear functional benefit in the options above. Good surgical technique at the time of primary CMN surgery is critical in minimising fatigue failure. After revision, overall mortality rates were equivalent to reported primary hip fracture mortality rates. Further multicentre evaluations are required to assess which technique convey the best functional outcomes without compromising 12-month mortality rates.

The changing face of fractures of the hip in Northern Ireland: a 15-year review

AIMS

We reviewed all patients who sustained a fracture of the hip and were treated in Northern Ireland over a period of 15 years to identify trends in incidence, the demographics of the patients, the rates of mortality, the configuration of the fracture and the choice of implant.

PATIENTS AND METHODS

Since 01 January 2001 data about every fracture of the hip sustained in an adult have been collected centrally in Northern Ireland. All adults with such a fracture between 2000 and 2015 were included in the study. Temporal changes in their demographics, the mode of treatment, and outcomes including mortality were analysed.

RESULTS

The incidence of fractures of the hip, in Northern Ireland, rose from 54 in 100 000 in 2000 to 86 in 100 000 in 2015. If these trends continue, we predict this rising to 128 in 100 000 in 2030. We found that these patients are becoming older and increasingly frail, as assessed by the American Association of Anesthesiology grade. Complex extracapsular fractures have become more common since 2009, which may explain the increased use of cephalomedullary nails. Despite increasing frailty, the 30-day and 12-month rates of mortality fell significantly (p = 0.002 and 0.001, respectively).

CONCLUSION

Fractures of the hip are becoming more common and more complex in an aging, increasingly frail population. We expect these trends to continue. This will place an increasing economic and clinical strain on healthcare systems. Forward planning is essential to put systems in place that can deal with the increasing demand. Cite this article: Bone Joint J 2017;99-B:1223-31.

Ultra-Early Combination Antiplatelet Therapy with Cilostazol for the Prevention of Branch Atheromatous Disease: A Multicenter Prospective Study

BACKGROUND AND PURPOSE

The optimal use of antiplatelet therapy for intracranial branch atheromatous disease (BAD) is not known.

METHODS

We conducted a prospective multicenter, single-group trial of 144 consecutive patients diagnosed with probable BAD. All patients were treated within 12 h of symptom onset to prevent clinical progression using dual antiplatelet therapy with cilostazol plus one oral antiplatelet drug (aspirin or clopidogrel). Endpoints of progressive BAD in the dual therapy group at 2 weeks were compared with a matched historical control group of 142 patients treated with single oral antiplatelet therapy using either cilostazol, aspirin, or clopidogrel.

RESULTS

Progressive motor paresis occurred in 14 patients (9.7%) in the aggressive antiplatelet group, compared with 48 (33.8%) in the matched single antiplatelet group. Multivariate logistic regression analysis revealed the following variables to be associated with a better prognosis for BAD: baseline modified Rankin Scale score, dual oral antiplatelet therapy with cilostazol, and dyslipidemia (odds ratios of 0.616, 0.445, and 0.297, respectively). Hypertension was associated with a worse prognosis for BAD (odds ratio of 1.955).

CONCLUSIONS

Our trial showed that clinical progression of BAD was significantly reduced with the administration of ultra-early aggressive combination therapy using cilostazol compared to treatment with antiplatelet monotherapy.

Is there any place for the variable angle proximal femoral plate? A case matched cohort study against the Dynamic Hip Screw system

INTRODUCTION

The Variable angle Martin Plate (MP) is designed to offer patient-specific adaption for the treatment of intertrochanteric hip fractures. Its proposed benefits include optimization of lag screw placement, plate shaft congruence and reduced risk of failure. Often its use has been criticized as representing a poor reduction of the fracture. The purpose of this study was to assess for a poorer quality of reduction, and compare functional outcomes and mortality, using a MP to that of a fixed angle Dynamic Hip Screw (DHS) in a matched cohort of patients.

METHODS

A retrospective review of a prospective fracture database system was undertaken between 1st January 2004 to 31st December 2013. MP patients were matched to a cohort of DHS patients. Outcomes measure were a quality of procedure score(QPS), 1-year mortality rates, reoperation rates, and Barthel Index functional outcome. Minimum follow up was 12 months.

RESULTS

A total of 77 Martin Plate patients were identified and case matched. The mean pre- and post-op Neck Shaft Angle (NSA) in the MPs was significantly different (132.97±7.78 Vs 126±8.62; p<0.0001). Conversely, the mean pre op DHS NSA and the mean post op NSA was not (p=0.397). Mean Tip-Apex Distance (TAD) was significantly different between groups; MP mean 26.51±9.09mm vs DHS 23.50±8.14mm (p=0.023). The QPS consisted of 4 variables. A significant inverse relationship between QPS and the incidence of construct related complications exists. TAD>25mm, and a change in AP NSA of >5°conveyed the greatest risk of complications. No difference occurred in complications, nor 12-month mortality.

CONCLUSIONS

No statistical difference was found in the quality of reduction between MP and DHS in this group of matched patients. QPS demonstrated a significant inverse correlation with implant-related complications. No significant difference was noted in the incidence of complications, Barthel Index functional scores, or 12-month mortality between implants. A rationale exists regarding the use of MPs, particularly in patients with varus NSA. However, planning and adequate reduction are essential regardless of implant choice.

Antibiotic Prophylaxis Regimens in Trauma and Orthopaedic Surgery: Are We Providing Adequate Cover Against Colonizing Organisms?

Trauma, elective orthopaedics, and an aging population will result in an increasing health burden and work load. The move to surgical podiatrists in the National Health Service within the United Kingdom will shift the surgical workload away from orthopaedic surgeons. A devastating complication of foot and ankle surgery is postoperative infection. While postoperative infection is multifactorial in etiology, concomitant diabetes mellitus increases the general risk of trauma and orthopaedic surgical site infections up to 8-fold. We therefore undertook a prospective study of our unit antibiotic prophylaxis regimes. Fifty patients participated. Swabs were obtained using aseptic technique from the plantar aspect of the feet, between the toes, and subsequently cultured on agar plates. Specimens were then incubated for 48 hours before being exposed to antibiotic plates. Cultured organisms were classified as susceptible to an antibiotic regimen if susceptibility to cefuroxime, or susceptibility to either drug of the flucloxacillin/gentamicin combination, was demonstrated. Statistical analysis e was performed. A P value <.05 was considered significant. Fifty patients were recruited, 26 (52%) were male. Mean age of 53 ± 19.4 years. The cohort included 15 diabetic, of which 11 (73.3%) insulin-dependent, and 35 nondiabetic patients. Comparing flucloxacillin/gentamicin against cefuroxime overall, susceptibility was noted in 84% and 70%, respectively (P = .096). Resistance to cefuroxime was significantly higher in diabetics than in nondiabetics (53% vs 25%, P = .046). The same pattern was observed for the flucloxacillin/gentamicin regimen (33% vs 9%, P = .049). While both regimens are active against colonizing organisms in this prospective observational study, flucloxacillin and gentamicin provide greater coverage overall. We have demonstrated that the use of flucloxacillin/gentamicin provides better coverage against commensal bacterial flora compared with cefuroxime alone. This is of even greater importance in the case of the specific high-risk subgroups, such as diabetic patients.

LEVELS OF EVIDENCE

Level IV: Case Series.