5 year follow up of a hydroxyapatite coated short stem femoral component for hip arthroplasty: a prospective multicentre study

Short stem, uncemented femoral implants for hip arthroplasty are bone conserving achieving stability through initial metaphyseal press-fit and biological fixation. This study aimed to evaluate the survivorship, mid-term function and health related quality of life outcomes in patients who have undergone total hip arthroplasty (THA) with a fully hydroxyapatite coated straight short stem femoral component with up to 5 years follow-up. 668 patients were recruited to a multicentre study investigating the performance of the cementless Furlong Evolution® stem for THA. 137 patients withdrew at various time points. The mean follow-up was 49 months. Clinical (Harris Hip Score (HHS), radiographic and patient-reported outcome measures-Oxford Hip Score (OHS) and EuroQol 5D (EQ-5D), were recorded pre-operatively and at 6 weeks, 6 months, 1 year, 3 year and 5 year follow ups. At 5-year follow-up, 12 patients underwent revision surgery, representing a cumulative revision rate of 1.8%. Median OHS, HHS and EQ5D scores improved significantly: OHS improved from a pre-operative median of 21 (IQR 14-26) to 47 (IQR 44-48) (p < 0.001). HHS improved from 52 (IQR 40-63) to 98 (IQR 92-100) (p < 0.001) and EQ5D improved from 70 (IQR 50-80) to 85 (IQR 75-95) (p < 0.001). This fully HA-coated straight short femoral stem implant demonstrated acceptable mid-term survivorship and delivered substantial improvements in function and quality of life after THA.

The loading patterns of a short femoral stem in total hip arthroplasty: gait analysis at increasing walking speeds and inclines

BACKGROUND

The purpose of this study was to examine the gait pattern of total hip arthroplasty (THA) patients with a new short femoral stem at different speeds and inclinations.

MATERIALS AND METHODS

A total of 40 unilateral THA patients were tested on an instrumented treadmill. They comprised two groups (shorter stemmed THA n = 20, longer stemmed THA n = 20), both which had the same surgical posterior approach. The shorter femoral stemmed patients were taken from an ongoing hip trial with minimum 12 months postop. The comparative longer THR group with similar disease and severity were taken from a gait database along with a demographically similar group of healthy controls (n = 35). All subjects were tested through their entire range of gait speeds and inclines with ground reaction forces collected. Body weight scaling was applied and a symmetry index to compare the implanted hip to the contralateral normal hip. An analysis of variance with significance set at α = 0.05 was used.

RESULTS

The experimental groups were matched demographically and implant groups for patient reported outcome measures and radiological disease. Both THA groups walked slower than controls, but symmetry at all intervals for all groups were not significantly different. Push-off loading was less favourable for both the shorter and longer stemmed THR groups (p < 0.05) depending on speed.

CONCLUSIONS

Irrespective of femoral stem length, symmetry for ground reaction forces for both THA groups were returned to a normal range when compared to controls. However individual implant performance showed inferior (p < 0.05) push-off forces and normalised step length in both THR groups when compared to controls.

LEVEL OF EVIDENCE

III.

Low-intensity pulsed ultrasound for treatment of tibial fractures: an economic evaluation of the TRUST study

AIMS

This 501-patient, multi-centre, randomised controlled trial sought to establish the effect of low-intensity, pulsed, ultrasound (LIPUS) on tibial shaft fractures managed with intramedullary nailing. We conducted an economic evaluation as part of this trial.

PATIENTS AND METHODS

Data for patients' use of post-operative healthcare resources and time taken to return to work were collected and costed using publicly available sources. Health-related quality of life, assessed using the Health Utilities Index Mark-3 (HUI-3), was used to derive quality-adjusted life years (QALYs). Costs and QALYs were compared between LIPUS and control (a placebo device) from a payer and societal perspective using non-parametric bootstrapping. All costs are reported in 2015 Canadian dollars unless otherwise stated.

RESULTS

With a cost per device of $3,995, the mean cost was significantly higher for patients treated with LIPUS versus placebo from a payer (mean increase = $3647, 95% confidence interval (CI) $3244 to $4070; p < 0.001) or a societal perspective (mean increase = $3425, 95% CI $1568 to $5283; p < 0.001). LIPUS did not provide a significant benefit in terms of QALYs gained (mean difference = 0.023 QALYs, 95% CI -0.035 to 0.069; p = 0.474). Incremental cost-effectiveness ratios of LIPUS compared with placebo were $155 433/QALY from a payer perspective and $146 006/QALY from a societal perspective.

CONCLUSION

At the current price, LIPUS is not cost-effective for fresh tibial fractures managed with intramedullary nailing. Cite this article: Bone Joint J 2017;99-B:1526-32.

Integrating cancer care beyond the hospital and across the cancer pathway: a patient-centred approach

Cancer patients constitute one of the most complex, diverse and growing patient populations in Canada. Like other high-needs patient groups, cancer patients desire a more integrated approach to care delivery that spans organizational and professional boundaries. This article provides an overview of Cancer Care Ontario's experience in fostering a more integrated cancer system, and describes the organization's emerging focus on patient-centred models of integrated care through the whole cancer pathway, from prevention to end-of-life care and survivorship.

Multidisciplinary cancer conferences as a forum for early identification of patients who can benefit from palliative care

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Background: Introducing palliative care early in the cancer journey results in a better quality of life, less aggressive care and longer survival compared to patients receiving standard care. The INTEGRATE Project goal is to identify and manage patients who can benefit from palliative care using the UK Gold Standards Framework Surprise Question (would you be surprised if this person died within the next year?). Multidisciplinary cancer conferences (MCCs) are scheduled meetings for oncology teams to prospectively discuss patient diagnostic tests and treatment options, which were leveraged for the INTEGRATE Project. Methods: A pilot study to test the efficacy of the Surprise Question at MCCs and implementation of a palliative model of care has been implemented in 3 academic and 1 non-academic cancer centres. A survey was completed to identify provider comfort levels in providing palliative care. All sites completed Pallium Canada’s LEAP Onco module, which equips providers with skills to provide primary level palliative care. Patients identified at MCCs received advance care planning, symptom management, referrals and standardized reporting to primary care. Results: Four disease sites (Lung, GI, CNS and Head & Neck) are participating. A baseline survey showed over 50% of providers had no training in palliative care. 161 providers participated in LEAP Onco. Implementation of the Surprise Question at MCCs began in February 2015. Two months of implementation identified 39 patients at the CNS, Lung and GI disease sites out of 108 of patients reviewed. At the CNS MCC, 100% glioblastoma patients were identified. The Lung and GI disease sites had lower identification rates (27% and 10%, respectively). Identified patients will have their healthcare utilization (referrals to community providers, billing patterns, ER visits) analyzed to determine impact of this project. Implementation continues until 2016. Conclusions: MCCs appear to be an excellent forum for identifying patients who can benefit from a palliative approach to care within the CNS, Lung and GI site groups. Further data is being collected to inform provincial recommendations for broader implementation of palliative care in Ontario.

Organ donor screening using parallel nucleic acid testing allows assessment of transmission risk and assay results in real time

Expansion of the donor pool may lead to utilization of donors with risk factors for viral infections. Donor laboratory screening relies on serological and nucleic acid testing (NAT). The increased sensitivity of NAT in low prevalence populations may result in false-positive results (FPR) and may cause unnecessary discard of organs.We developed a screening algorithm to deal, in real time, with potential FPR. Three NAT assays: COBAS AmpliScreen assay (CAS), AmpliPrep Total Nucleic Acid Isolation/CAS, and AmpliPrep/TaqMan assays, were validated and used in parallel for prospective screening of increased-risk donors (IRD), and the probability of FPR was calculated. The lower limit of detection of this algorithm was 9.79, 21.02, and 4.31 IU/mL for human immunodeficiency virus-1, hepatitis C virus, and hepatitis B virus, respectively, with an average turn-around-time of 7.67 h from sample receipt to result reporting. The probability that a donor is potentially infectious with two NAT concordant results was >90%. NAT screening of 35 IRD within 18 months resulted in transplantation of 102 additional organs that without screening would either not be used or used with restrictions in Australia. Using a parallel testing algorithm, real-time confirmation of seropositive donors allows use of organs from IRD and safer expansion of the donor pool.