Albumin is an Independent Predictor of up to 9-Year Mortality for Intracapsular Femoral Neck Fractures Aiding in Decision-Making for Total Hip Arthroplasty or Hemiarthroplasty.

BACKGROUND: Intracapsular femoral neck fractures in the geriatric population are usually treated with hemiarthroplasty or total hip arthroplasty. The patients' medium-term to long-term mortality is a consideration to help decide which procedure to perform. The aim of this study is to examine whether easily identifiable serum investigations and patient identifiable factors on admission are associated with medium-term and long-term mortality. METHODS: A consecutive series of 331 patients who sustained intracapsular femoral neck fractures and were over the age of 55 years were identified and retrospectively reviewed. American Society of Anesthesiologists (ASA) grade, cognitive function, gender, age, mobility status, and admission serum investigations were considered. RESULTS: Low albumin levels, advanced age, men, and a combination of high ASA with lower mobility status were independent predictors of mean 5-year mortality. Similarly, low albumin levels and a combination of high ASA with lower mobility status were found to be independent predictors of longer term mortality (7-9 years). The optimal albumin cut-off to identify patient survival was >42 g/L with an area under the curve of 0.71. CONCLUSION: We suggest that serum albumin on admission can be utilized as a factor to identify patients who are likely to survive at up to 9-year mean follow-up, to guide decision for total hip arthroplasty over hemiarthroplasty.

Patients With Un-Displaced Or Displaced Intra Capsular Proximal Femur Fractures Do Not Represent A Different Patient Group And Have Similar Short And Long Term Mortality.

BACKGROUND: Proximal femur fractures in geriatric patients are associated with substantial mortality. Management of intracapsular proximal femur fractures has been based on age, displacement, cognition, and pre-injury mobility. However, over the last decade, there has been a tendency to offer arthroplasty rather than internal fixation for these patients irrespective of displacement, to allow early mobilisation and negate the higher rate of reoperation due to failed internal fixation. There are no previous investigations analysing whether the severity of fracture displacement is related to different patient characteristics. AIM: This study examines whether patients sustaining undisplaced or displaced intracapsular proximal femur fractures represent different patient groups with different pre-injury characteristics and post-operative mortality, irrespective of treatment modality. METHODS: A retrospective series of 329 consecutive patients over the age of 55 years who sustained intracapsular proximal femur fractures, who underwent surgical management at a district general hospital over a period of 2 years (2012-2013) were identified using the national hip fracture database. Demographics, American Society of Anaesthesiologist (ASA) grade, pre-injury outdoor mobility status, cognitive status, and admission serum investigations, fracture displacement, type of surgery, and mortality rates at short term (2 years) & long-term (7-9 years) were reviewed. RESULTS: There were 109 male and 220 female patients with a minimum follow-up of 7 years. The mean age at surgery was 81.6 years (range 55-103 years). There were 63 (19.1%) undisplaced fractures (Garden 1 &2) and, 265 (80.5%) displaced fractures (Garden 3 & 4). The median survival in this cohort was 2.95 years (95% CI 2.3-3.6). Mortality rates were 77.4% (n=257) at long-term (7-9 years) follow-up. Admission patient characteristics showed no statistically significant difference between displaced and undisplaced fracture groups. This included ASA, pre-operative cognition, and mobility status. Fracture displacement was not an independent predictor of mortality at short or long term. CONCLUSION: In patients sustaining intracapsular proximal femur fractures, the degree of displacement is not a caveat for a different patient group. Fracture displacement is not predicted by the pre-injury level of function and does not predict short or long-term mortality.

Patellotrochlea Index in Normal Healthy Knees.

Patella alta is a common and significant abnormality responsible for many patellofemoral joint-related conditions. Many methods of patella height measurements are described; however, patellotrochear index (PTI) is the most logical method as it measures the direct relation between patella and trochlea. The aim of this study is to investigate PTI in normal healthy asymptomatic volunteers to understand the patellofemoral relation in normal knees. Twenty-five healthy volunteers underwent magnetic resonance imaging (MRI) scans of both knees. Two observers independently measured PTI on two different occasions at 6-week interval. Statistical analysis was performed to identify intra- and interobserver correlation between two observers and the mean value of PTI. Agreement analysis was performed according to Bland and Altman. Comparisons of means were made using paired t-tests. The mean age of 25 healthy volunteers was 21.28 years (19-23) with a male:female ratio of 14:11. The overall mean PTI value of all observations was 36.8% and pooled standard deviation (SD) 11.5%. Intraclass correlation (ICC) testing showed "good" interobserver ICC between two observers for PTI for both first (0.80) and second (0.84) set of measurements. There was "excellent" intraobserver correlation for two sets of measurements of PTI made by each first (0.96) and second (0.91) observer. Intraobserver repeatability for PTI was ± 0.07 and ± 0.1, respectively, for the first and second observer. Interobserver repeatability for PTI was ± 0.159 and ± 0.133, respectively, for the first and second set of measurements. Analysis of individual measurements of patella and trochlear articular cartilage revealed that the largest repeatability values were for trochlea measurements. The study reports that the average PTI in asymptomatic healthy knee utilizing current clinical MRI scanning conditions is 36.8%. This provides surgeons with a gold standard normal PTI value, which can serve as a target value in clinical diagnosis as well as surgical correction of patella height. There is good to excellent intra- and interobserver correlation with limited variability in assessing patella height using PTI on MRI scan.

The innominate tubercle of the femur is a consistent surgical landmark and shows no variation between sex and side: An osteological study.

INTRODUCTION: During direct anterior approach hip arthroplasty, the innominate tubercle (IT) of the femur is used as a reference point for femoral neck osteotomy. A recent study found that IT dimensions are unaffected by femoral length, neck-shaft angle, and neck length. This study investigated the position of the tubercle relative to femoral side, sex and femoral neck dimensions. MATERIALS AND METHODS: One hundred and ninety femora (95 pairs, complete with biographical data) from St. Bride's Church, London, were photographed with the apex of the tubercle marked. Using imaging software, axes were superimposed onto the image, allowing the X and Y co-ordinates of the tubercle apex to be derived. Statistical analysis was carried out. RESULTS: The position of the tubercle did not vary significantly and did not correlate with femoral side (p > .05). P values for variation of the X and Y coordinates were 0.351 and 0.996 in left and right femora, respectively. The tubercle position did not vary significantly with sex (p > .05). p Values for variation of the X and Y coordinates were 0.254 and 0.634 in males and females, respectively. There was little variation between tubercle position and femoral neck dimensions: correlation coefficient -0.20 (x coordinate) and -0.12 (y coordinate). CONCLUSIONS: The data showed that the position of the IT did not vary significantly with either sex or side and that, therefore, the tubercle can be considered a reliable surgical landmark during arthroplasty surgery.

Perceived Barriers to Participation in Clinical Research Amongst Trauma and Orthopaedic Community: A Survey of 148 Consultants and Junior Doctors in Wales.

BACKGROUND: Research has led to substantial improvement in health and quality of life. It is pertinent for doctors to participate in research to keep up with the advances of modern medicine and forms one of the seven pillars of clinical governance defined by the General Medical Council. However, clinicians face multiple barriers to participating in research. The objective of this study was to identify barriers in participation and to recommend solutions for better engagement in orthopaedic research. METHODOLOGY: Trauma and Orthopaedic consultants and junior doctors in Wales were asked to complete a web-based survey with 15 questions about barriers to participation and suggestions for increasing involvement in clinical research. RESULTS: A total of 148 completed forms were received which included 60 consultants and 88 junior doctors. The response rate was 86%. The most frequently reported barriers to clinical research were time constraints, excess paperwork, lack of knowledge about research methods, and lack of awareness of ongoing research studies. Most participants were keen to be involved in research in the future. Majority responded that they would more likely take part in research activity if there were formal training sessions and more dedicated research sessions scheduled into their timetable. Need for more incentives and allocation of a research officer were other suggestions. Most orthopaedic staff recognised the relevance of research to their job/training.  Conclusion: There are multiple perceived barriers to participating in research at all levels in the orthopaedic community; however, these could be mitigated by implementing simple measures.

Patella Height as Defined by Patella-Trochlear Articulation on MRI Scan-A Systemic Review of Current Evidence.

The objective of this study is to investigate what are the normal values, cutoff values, and optimal method of magnetic resonance imaging (MRI) scan for patella height focusing on patella-trochlear index (PTI). Electronic searches of MEDLINE (PubMed), Cumulative Index to Nursing and Allied Health Literature, Cochrane, Embase, ScienceDirect, and National Institute for Health and Care Excellence evidence up to April 2018 were completed. Eligibility criteria for selected studies included case-controlled studies, prospective cohort studies, cross-sectional and randomized controlled trials reporting on the use of MRI to evaluate direct patella height. Exclusions included animal or biomechanical/computational studies; interventional surgery such as knee arthroplasty, bracing, or realignment; and hereditary/congenital disease. A quality assessment of included studies was completed using the Methodological Index for Non-Randomized Studies (MINORS) Criteria. Sixty-four articles were identified which met the inclusion criteria. Following exclusions, 11 full-text studies were reviewed which reported direct measure of patella height. Nine studies reported the use of PTI. Two low power studies described PTI in normal healthy asymptomatic knee. Similarly, one study evaluated the effect of flexion and weight bearing on PTI values. The cutoff values varied between studies from <0.125 to <0.28 for patella alta and >0.50 to >0.80 for patella baja. This review found that currently, there are a very few studies on the assessment of PTI on MRI scan, with only two low powered studies on a true normal population. In view of this, there is a need for adequately powered studies to investigate patella height and PTI in asymptomatic healthy knees.

Plasma Viscosity Has a Role in the Diagnosis of Prosthetic Joint Infection After Total Knee Arthroplasty.

BACKGROUND: The diagnosis of prosthetic joint infection (PJI) is challenging because no single test has consistently demonstrated an adequate discriminative potential. The combination of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) with adequate thresholds is well established. This study sought to investigate the role of plasma viscosity (PV) in the diagnosis of PJI following painful total knee arthroplasty. METHODS: The medical notes, and hematological and microbiology results of 310 patients who underwent revision for a painful total knee arthroplasty were evaluated. Infection was confirmed using Musculoskeletal Infection Society criteria in 102 patients (32.9%), whereas 208 patients (67.1%) were classified as noninfected. Serum investigations including ESR, CRP, and PV were analyzed using receiver observer curves and optimal cutoff points identified. RESULTS: There was a strong correlation between PV and both ESR and CRP. The area under curve was 0.814 for PV and 0.812 for ESR. Statistical analysis showed noninferiority of PV as compared to ESR in diagnosing PJI. A PV value of ≥ 1.81 mPa.s. had the best efficiency of 82.1%. Combining a CRP ≥ 13.5 mg/L with a PV ≥ 1.81 mPa.s. in a serial test approach yielded the highest specificity of 97.9% and positive likelihood ratio of 22.8. Sensitivity was 47.9% and a negative likelihood ratio of 0.53. CONCLUSION: PV is noninferior to ESR in diagnosing PJI. Its use is justified in clinical practice. It is cheaper, quicker, more efficient, and not influenced by hematocrit levels or medication. In this cohort, a PV value ≥ 1.81 mPa.s. would be an adequate cutoff to diagnose PJI in combination with CRP ≥ 13.5 mg/L.

Ten-year results for a single-surgeon series of Scorpio non-restrictive geometry (NRG) posterior stabilised (PS) total knee replacement.

BACKGROUND: To report the long-term results for a single-surgeon consecutive series of Scorpio non-restrictive geometry (NRG) posterior stabilised (PS) total knee replacement (TKR). MATERIALS AND METHODS: Forty-six consecutive patients who underwent 53 Scorpio NRG PS were identified. Change in range of motion (ROM) and Oxford Knee Score (OKS) over time were recorded. Radiographs were evaluated for alignment and radiolucent lines. Survival analysis for the prosthesis was calculated. RESULTS: At a mean of 10.1 years (range 9.1-10.9) following exclusions thirty-seven (69.8%) knees in thirty-one (67.4%) patients (6 bilateral) were available for review. None of the patients required revision surgery. Mean OKS score at 10 years was 37.8. The mean ROM significantly improved from 95° pre-operative to 117.5° at 5 years and 115° at 10 years (p = < 0.001). This equates to a value-added range of motion (VAROM) of 19° at 5 years and 15.6° at 10 years. There was a correlation between OKS and VAROM at 5 and 10 years. Radiological assessment did not reveal any evidence of progressive cement radiolucent lines nor component migration. CONCLUSION: In this series the Scorpio NRG PS showed 100% 10-year survivorship. We found a significant improvement in ROM and VAROM over time. This was not associated with increased signs of loosening.

Predictors of fracture healing in patients with recalcitrant nonunions treated with autologous culture expanded bone marrow-derived mesenchymal stromal cells.

The study reports the prospective outcome of treating severe recalcitrant fracture nonunion in patients with autologous bone marrow-derived mesenchymal stromal cells (BMSC) from 2003 to 2010 and analyze predictors of union. Autologous BMSC were culture expanded and inserted at nonunion site with or without carriers in addition to surgical stabilization of the fracture. Radiological union was ascertained by musculoskeletal radiologists on plain radiographs and/or CT scans. A logistic regression analysis was performed with cell-expansion parameters (cell numbers, cell doubling time) and known clinical factors (e.g., smoking and diabetes) as independent variables and fracture union as the dependent variable to identify the factors that influence bony healing. An Eq5D index score assessed the effect of treatment on general quality of health. A total of 35 patients (mean age 51+/-13 years) with established nonunion (median 2.9 years, 1-33) and, at least one failed nonunion surgery (median 4,1-14) received treatment. Fracture union was achieved in 21 patients (60%; 95%CI 44-75) at 2.6 years. Multiple penalized logistic regression revealed faster cell doubling time (p = 0.07), absence of diabetes (p = 0.003), less previous surgeries (p = 0.008), and lower age at cell implantation (p = 0.02) were significant predictors for fracture union. A significant increase in Eq5D index (p = 0.01) was noted with a mean rise of the score by 0.34 units (95%CI 0.11-0.58) at 1 year following the study. In summary, the study revealed cell doubling time as a novel in vitro parameter in conjunction with age, multiple surgeries, and diabetes as being significant predictors of the fracture union. © 2018 The Authors. Journal of Orthopaedic Research® Published by Wiley Periodicals, Inc. J Orthop Res 37:1303-1309, 2019.

Reliability evaluation of inter-eminence line, Akagi and Dalury lines for intraoperative tibial rotation: An osteology-based study.

BACKGROUND: This large osteology study examined the reliability, reproducibility and correlation between previously described tibial tray rotation alignment lines (including Akagi and Dalury lines). In addition, it described a novel inter-eminence line utilising the tibial plateau inter-condylar eminences as a landmark. METHODS: A total of 214 post-medieval (18-19th centuries) skeletal tibia were examined. The inter/intra-observer variation and correlation between reference lines were measured. RESULTS: Inter-observer reproducibility was excellent and there were no differences between Akagi, Dalury, and inter-eminence lines. Similarly, intra-observer reliability was excellent for Akagi, Dalury, and inter-eminence lines. Qualitative review of tibial inter-condylar eminences suggested that these could be easily identifiable. When taking the medial angle from a medial-lateral reference line, the Akagi line showed a mean of 96.90° (±10.27), inter-eminence line 94.52° (±12.84), and Dalury line 88.06° (±11.75). The angle produced by the Dalury line was significantly different from both the Akagi and inter-eminence lines (P≤0.001). The Akagi line and inter-eminence line showed a strong correlation (r=0.74). The Dalury line showed a weaker correlation with both the Akagi line (r=0.69) and inter-eminence line (r=0.40). CONCLUSION: This study suggested that tibial rotation lines showed excellent intra/inter-observer reliability and reproducibility. The novel and easily drawn inter-eminence line showed strong correlation with the Akagi line and could be used for tibial tray rotational alignment in total knee arthroplasty.

Improving consent form documentation and introduction of procedure-specific labels in a district general hospital.

Informed consent is an important aspect in patient care. Failings in this area may result in patient dissatisfaction or litigation. The aim of this project was to assess our practice in consenting and institute changes to maintain best practice. A consecutive series of 140 patients undergoing elective and trauma procedures were randomly identified over a nine-month period. The consent forms were reviewed and the following information collected: patient/ consenter details, procedure, legibility, if copy was offered/ given to patient and adequacy of procedure-specific complications listed (scored 0-3). The issues identified included: 25% of consents were not fully legible particularly in the complications section. 62% were noted to have inadequate complications listed (score 0 [>5 risks missing]) when compared to an accepted standard. None of the consent form copies were offered or given to the patients. Focused teaching to juniors as well as procedure-specific complication stickers were implemented to improve the documentation of complications. Following several improvement cycles all consents (100%) were fully legible and had the adequate procedure-specific labels with all complications listed. There was an increase to 38% of consent forms offered to patients. We have asked surgeons in the department to comment on which consent method they prefer and all consenters felt that the procedure-specific labels where easier to read and understand. Departmental education as well as introduction of simple procedure-specific complication stickers has resulted in significant improvements in practice.

Psychometric properties including reliability, validity and responsiveness of the Majeed pelvic score in patients with chronic sacroiliac joint pain.

PURPOSE: The Majeed scoring system is a disease-specific outcome measure that was originally designed to assess pelvic injuries. The aim of this study was to determine the psychometric properties of the Majeed scoring system for chronic sacroiliac joint pain. METHODS: Internal consistency, content validity, criterion validity, construct validity and responsiveness to change was assessed prospectively for the Majeed scoring system in a cohort of 60 patients diagnosed with sacroiliac joint pain. This diagnosis was confirmed with CT-guided sacroiliac joint anaesthetic block. RESULTS: The overall Majeed score showed acceptable internal consistency (Cronbach alpha = 0.63). Similarly, it showed acceptable floor (0 %) and ceiling (0 %) effects. On the other hand, the domains of pain, work, sitting and sexual intercourse had high (>30 %) floor effects. Significant correlation with the physical component of the Short Form-36 (p = 0.005) and Oswestry disability index (p ≤ 0.001) was found indicating acceptable criterion validity. The overall Majeed score showed acceptable construct validity with all five developed hypotheses showing significance (p ≤ 0.05). The overall Majeed score showed acceptable responsiveness to change with a large (≥0.80) effect size and standardized response mean. CONCLUSION: Overall the Majeed scoring system demonstrated acceptable psychometric properties for outcome assessment in chronic sacroiliac joint pain. Thus, its use in this condition is adequate. However, some domains demonstrated suboptimal performance indicating that improvement might be achieved with the development of an outcome measure specific for sacroiliac joint dysfunction and degeneration.

Pre-operative nutritional serum parameters as predictors of failure after internal fixation in undisplaced intracapsular proximal femur fractures.

INTRODUCTION: Current management of undisplaced hip fractures is based on internal fixation. Reported revision rates of 12-17% for this procedure negatively impact on patient morbidity and mortality. The aim of this novel study is to examine if the nutritional status of these patients is associated with failure of internal fixation. PATIENTS AND METHODS: A consecutive series of 111 undisplaced intracapsular hip fractures treated with cannulated screw was identified. These were retrospectively reviewed including routine admission serum investigations (lymphocyte count and albumin levels). Radiological investigations were used to assess fracture classification, posterior-tilt angle, fixation adequacy, screw configuration and failure (avascular-necrosis, non-union and screw cut-out). RESULTS: 16% of fixations failed (18 patients). Patients with fixation-failure had a significantly lower albumin (35g/l vs. 40g/l, p=0.02) and lymphocyte count (0.7×10(9)l vs. 1.4×10(9)l, p≤0.001) than non-failure patients. Lymphocyte count, albumin level and posterior-tilt angle were independent predicators of failure on binary logistic regression analysis. We suggest that routine laboratory tests can be used to identify patients at greatest risk of failure of internal fixation.

Decreased osteogenesis, increased cell senescence and elevated Dickkopf-1 secretion in human fracture non union stromal cells.

The delicately orchestrated process of bone fracture healing is not always successful and long term non union of fractured bone occurs in 5-20% of all cases. Atrophic fracture non unions have been described as the most difficult to treat and this is thought to arise through a cellular and local failure of osteogenesis. However, little is known about the presence and osteogenic proficiency of cells in the local area of non union tissue. We have examined the growth and differentiation potential of cells isolated from human non union tissues compared with normal human bone marrow mesenchymal stromal cells (BMSC). We report the isolation and culture expansion of a population of non union stromal cells (NUSC) which have a CD profile similar to that of BMSC, i.e. CD34-ve, CD45-ve and CD105+ve. The NUSC demonstrated multipotentiality and differentiated to some extent along chondrogenic, adipogenic and osteogenic lineages. However, and importantly, the NUSC showed significantly reduced osteogenic differentiation and mineralization in vitro compared to BMSC. We also found increased levels of cell senescence in NUSC compared to BMSC based on culture growth kinetics and cell positivity for senescence associated beta galactosidase (SA-beta-Gal) activity. The reduced capacity of NUSC to form osteoblasts was associated with significantly elevated secretion of Dickkopf-1 (Dkk-1) which is an important inhibitor of Wnt signalling during osteogenesis, compared to BMSC. Conversely, treating BMSC with levels of rhDkk-1 that were equivalent to those levels secreted by NUSC inhibited the capacity of BMSC to undergo osteogenesis. Treating BMSC with NUSC conditioned medium also inhibited the capacity of the BMSC to undergo osteogenic differentiation when compared to their treatment with BMSC conditioned medium. Our results suggest that the development of fracture non union is linked with a localised reduced capacity of cells to undergo osteogenesis, which in turn is associated with increased cell senescence and Dkk-1 secretion.

Updates on stem cells and their applications in regenerative medicine.

Stem cells have the capacity for self-renewal and capability of differentiation to various cell lineages. Thus, they represent an important building block for regenerative medicine and tissue engineering. These cells can be broadly classified into embryonic stem cells (ESCs) and non-embryonic or adult stem cells. ESCs have great potential but their use is still limited by several ethical and scientific considerations. The use of bone marrow-, umbilical cord-, adipose tissue-, skin- and amniotic fluid-derived mesenchymal stem cells might be an adequate alternative for translational practice. In particular, bone marrow-derived stem cells have been used successfully in the clinic for bone, cartilage, spinal cord, cardiac and bladder regeneration. Several preclinical experimental studies are under way for the application of stem cells in other conditions where current treatment options are inadequate. Stem cells can be used to improve healthcare by either augmenting the body's own regenerative potential or developing new therapies. This review is not meant to be exhaustive but gives a brief outlook on the past, present and the future of stem cell-based therapies in clinical practice.

Rosella parrot exposure as a cause of bird fancier's lung.

A case of a 30-year-old man who presented with a 2-month history of progressively worsening dyspnoea, cough, and reduced exercise tolerance is discussed. A chest x-ray and computerized tomography of the chest suggested interstitial lung disease, which was confirmed on histology of an open lung biopsy. Careful questioning revealed that the patient had sustained close exposure to a rosella parrot acquired as a pet 9 months prior to presentation, which led to the diagnosis of bird fancier's lung. The case, investigations, and outcome are presented. This is followed by a discussion on extrinsic allergic alveolitis with particular emphasis on the importance of a complete social and environmental history in patients presenting with similar respiratory symptoms.