Covid-19: Exploring medico-legal perceptions amongst orthopaedic surgeons and lawyers.

INTRODUCTION: British national guidelines and laws published by the British Orthopaedic Association and the new Coronovirus Act 2020 favoured treatment of trauma and orthopaedic conditions with non-operative alternatives.A survey was developed for both lawyers and trauma and orthopaedic clinicians to gauge their perceptions on guidelines related to protection of trauma and orthopaedic staff, and on prosecution with respect to future claims. MATERIAL AND METHODS: Sixteen questions were designed for surgeons and 11 questions for lawyers. The level of experience and career stages were explored in other questions. A Likert scale (0-5) was used to capture these perceptions. RESULTS: Clinicians envisaged themselves being less protected (mean = 2.6), forecasted a rise in negligence claims (mean = 3.4) and perceived little additional beneficial indemnity influence from the NHS (mean = 1.8). Lawyers felt that public perception would have more influence in negligence claim rates (mean = 2.6) and disapproved of complete immunity for clinicians (mean = 0.5). Disparities between different trauma and orthopaedic grades demonstrated sentiments of comfort with redeployment, preparedness in non-orthopaedic training and protection from litigation. DISCUSSION: The results reflected the overall anxiety over litigation reprisal shared amongst trauma and orthopaedic staff. Issues with providing sub-optimal care can worsen this overall fear. Feeling unprotected from litigation reprisal can leave clinicians with an additional sense of emotional and professional burden. Redeployment into unfamiliar environments can leave senior clinicians in limbo in contrast to their juniors. CONCLUSION: Non-surgical options to treat orthopaedic conditions affect both patients and trauma and orthopaedic staff. Feedback from lawyers reassures trauma and orthopaedic clinicians that negligence claims should not rise due to the updated national guidelines.

Length of hospital stay following hip fracture and risk of 30 and 90 day mortality in a United Kingdom cohort.

A recent study identified a length of stay (LOS) of 10 days or less following hip fracture is associated with increased risk of 30-day mortality. This effect has not been previously studied for 90-day mortality or in the United Kingdom (UK). Our aim was to investigate the effect of LOS on 30-day and 90-day mortality following hip fracture in a UK population. In this single-centre study, we retrospectively identified consecutive patients with a hip fracture from the National Hip Fracture Database over 3 years. We excluded patients who died as inpatient during their index admission. The main end-points were 30-day and 90-day mortalities and risk factors for these were examined using stepwise univariate and multivariate Cox regression analyses. Of 1228 patients, mortality at 30-days was 1.2% (15 patients) and 7.8% (96 patients) at 90-days. Mean LOS was 24 days and a total of 206 patients had a LOS of 10 days or less. Following cariate analysis, the highest risk factor for 30-day mortality was a LOS of 10 days or less with a hazard ratio of 7.26 (95% confidence interval 2.56-20.51). Other risk factors for 30-day mortality included increasing age, male gender and chest infection. A LOS of 10 days or less was not associated with increased mortality at 90-days. A short LOS was associated with higher risk of early mortality. We recommend that hip fracture patients be fully rehabilitated prior to discharge to reduce the risk of early mortality.

Short-term risk factors for a second hip fracture in a UK population.

INTRODUCTION: A hip fracture carries significant morbidity and mortality-a second fracture of the contralateral hip carries even higher complications. Most second hip fractures occur within 48 months of the first. The aim of this study was to comprehensively analyse all identifiable variables that may increase the risk of a contralateral hip fracture within this time period. METHODS: We retrospectively analysed 1242 consecutive patients with hip fractures presenting to our institution. All patient-related, surgery-related and inpatient variables were collected from the index admission. We then identified patients with a subsequent contralateral hip fracture in the following 2 years. Univariate and multivariate analyses were performed to identify risk factors associated with a second fracture. RESULTS: A total of 66 patients (5.3%) had a contralateral hip fracture in the 2 years following initial hip fracture. Mean age at first presentation was 81 years, and mean time to second fracture was 305 days. Following multivariate analysis, the patients at highest risk of a second fracture were those with dementia, acute inpatient chest infection, urinary tract infection and multiple comorbidities as measured by the Charlson score. Discharge destination after initial fracture was not associated with the risk of a second fracture. CONCLUSIONS: We have identified a number of discrete risk factors that are associated with a short- to medium-term risk of contralateral hip fracture that may be useful in screening for patients at risk and provide them with focused medical rehabilitation.

There is no weekend effect in hip fracture surgery - A comprehensive analysis of outcomes.

BACKGROUND: Previous studies have shown that some patient groups suffer adverse outcomes if they are acutely admitted to hospital over a weekend. We aimed to investigate this 'weekend effect' at our centre in patients presenting with a hip fracture. METHODS: Consecutive patients undergoing acute hip fracture surgery were identified from a prospective database. Patient demographics, co-morbidities, fracture type, admission blood parameters were examined. Outcomes analysed included 30-day, 90-day and 1-year mortality as well as length of stay, re-operations and delay to surgery. The data were analysed with regards to day of admission and day of surgery separately. RESULTS: A total of 1326 patients were included, of which 368 patients were admitted over a weekend and 411 patients had their operation over a weekend. Overall 30-day mortality was 7.6% (101 patients), whilst the 90-day and 1-year mortalities were 15.3% and 26.8% (203 and 356 patients). There were no significant differences in any of the outcomes based on the day of admission or the day of surgery. Multivariate analysis for 30-day mortality demonstrated the following variables to be significant predictors: admission urea levels (hazard ratio (HR) 1.042, p = 0.027), age (HR 1.058, p < 0.001), admission source (HR 1.428, p < 0.001), surgical delay >48 h (HR 1.853, p = 0.004), male gender (HR 1.967, p = 0.003), previous stroke (HR 2.261, p = 0.038), acute chest infection (4.240, p < 0.001) and chronic liver disease (HR 4.581, p = 0.014). CONCLUSION: This data suggests that there is no significant weekend effect in hip fracture surgery and mortality is affected by patient co-morbidities and delay to surgery.

Prevention of limb length discrepancy in total hip arthroplasty.

Total hip arthroplasty is a highly effective and cost-efficient procedure but postoperative limb length discrepancy is a common source of patient dissatisfaction and litigation. This article provides a systematic, stepwise approach for identifying and proactively managing risk factors associated with limb length discrepancy following total hip arthroplasty. This review explores preoperative history taking, clinical examination, radiological templating, implant positioning, soft tissue balancing, and intraoperative surgical techniques for minimizing leg length discrepancy while maintaining stability and restoring mechanical function following total hip arthroplasty. A comprehensive understanding of the multifactorial nature and methods for reducing postoperative limb length discrepancy is essential for optimizing patient satisfaction, clinical outcomes and long-term function following total hip arthroplasty.

Midterm results of 36 mm metal-on-metal total hip arthroplasty.

BACKGROUND: Despite the many perceived benefits of metal-on-metal (MoM) articulation in total hip arthroplasty (THA), there have been growing concerns about metallosis and adverse reaction to metal debris (ARMD). Analysis of size 36 mm MoM articulation THAs is presented. These patients were evaluated for patient characteristics, relationship between blood metal ions levels and the inclination as well as the version of acetabular component, cumulative survival probability at final followup and functional outcome at final followup. MATERIALS AND METHODS: 288, size 36 mm MoM THAs implanted in 269 patients at our institution from 2004 to 2010 were included in this retrospective study. These patients were assessed clinically for hip symptoms, perioperative complications and causes of revision arthroplasty were analysed. Biochemically, blood cobalt and chromium metal ions level were recorded and measurements of acetabular inclination and version were examined. Radiological evaluation utilizing Metal Artefact Reduction Sequence (MARS) MRI was undertaken and implant cumulative survivorship was evaluated. RESULTS: The mean followup was 5 years (range 2-7 years), mean age was 73 years and the mean Oxford hip score was 36.9 (range 5-48). Revision arthroplasty was executed in 20 (7.4%) patients, of which 15 patients underwent single-stage revision THA. The causes of revision arthroplasty were: ARMD changes in 6 (2.2%) patients, infection in 5 (1.9%) patients and aseptic loosening in 5 (1.9%) patients. Three (1.1%) patients had their hips revised for instability, 1 (0.3%) for raised blood metal ions levels. The implant cumulative survival rate, with revision for any reason, was 68.9% at 7 years. CONCLUSIONS: Although medium-sized MoM THA with a 36 mm head has a marginally better survivorship at midterm followup, compared to larger size head MoM articulating THA, our findings nonetheless are still worryingly poor in comparison to what has been quoted in the literature. Furthermore, ARMD-related revision remains the predominant cause of failure in this cohort with medium-sized MoM articulation. No correlation was found between blood metal ions levels and the inclination as well as the version of acetabular component.

Panton-Valentine leukocidin osteomyelitis in children: a growing threat.

Panton-Valentine leukocidin-producing Staphylococcus aureus osteomyelitis is associated with multiple complications including multiple abscesses, deep vein thrombosis and fulminant sepsis. This article reviews the literature concerning this emerging threat which is currently under-recognized.

Is discontinuation of clopidogrel necessary for intracapsular hip fracture surgery? Analysis of 102 hemiarthroplasties.

BACKGROUND: An increasing number of elderly patients are managed with long-term antiplatelet therapy. Such patients often present with hip fracture requiring surgical intervention and may be at increased risk of perioperative bleeding and complications. The aim of this study was to ascertain whether it is necessary to stop clopidogrel preoperatively to avoid postoperative complications following hip hemiarthroplasty surgery in patients with intracapsular hip fracture. MATERIALS AND METHODS: A retrospective review of 102 patients with intracapsular hip fracture with either perioperative clopidogrel therapy [clopidogrel group (CG)] or no previous clopidogrel exposure [no clopidogrel group (NCG)] who underwent hip hemiarthroplasty surgery was undertaken. Statistical comparison on pre- and postoperative haemoglobin, American Society of Anesthesiologists (ASA) grade, comorbidities, operative time, transfusion requirements, hospital length of stay (LOS), wound infection, haematoma and reoperation rate between the two groups was undertaken. Regression analysis was undertaken to ascertain the risk ratios (RR) of complications and transfusion associated with clopidogrel. RESULTS: There was no difference with respect to ASA grade, comorbidities (except cardiac comorbidities), pre- and postoperative haemoglobin levels, operation time, age or gender between the two groups. Four and two patients, respectively, required transfusion postoperatively in the CG and NCG (p = 0.37). There was no difference with respect to LOS, wound infection, haematoma or reoperation rate between the two groups postoperatively. The covariate-adjusted RR for complications and transfusion while being on clopidogrel were 0.43 [95% confidence interval (CI) 0.07-2.60] and 3.96 (95% CI 0.40-39.68), respectively. CONCLUSION: Continuing clopidogrel therapy throughout the perioperative period in patients with intracapsular hip fracture is not associated with an increased risk of complications following hip hemiarthroplasty surgery.

The accuracy of primary care teams in diagnosing disorders of the shoulder.

OBJECTIVE: The aim of this retrospective, observational study was to determine the accuracy of diagnoses given by a multitude of primary care services to patients referred to an orthopaedic upper limb surgeon with a focus towards shoulder pathology. METHODS: Records of all patients referred to a single upper limb surgeon over a 1-year period were reviewed. The diagnosis in the primary care setting was compared with the initial working diagnosis in the specialist clinic and against the final diagnosis following specialist investigation/intervention. RESULTS: 114 eligible patients were identified. General practitioners referred 35% of patients, musculoskeletal triage services referred 63% of patients and independent physiotherapists referred 2% of patients. It was found that 37% of patients were not given a diagnosis by the primary care team. When a diagnosis was given, accuracy was 50% (κ = 0.28) when correlated against that given by an orthopaedic upper limb surgeon. CONCLUSIONS: Our findings suggest that knowledge of shoulder conditions is limited amongst primary care practitioners. There does not appear to be any difference in accuracy between general practitioners and musculoskeletal triage services.

Factors influencing foundation programme choice among medical students.

OBJECTIVES: The advent of Modernising Medical Careers has replaced the traditional pre-registration house officer (PRHO) year and first year of senior house officer (SHO) training with a combined foundation programme. The aim of this study was to find out the factors influencing choice of foundation programme among medical students. DESIGN: Prospective survey. SETTING: Three medical schools based in England. MAIN OUTCOME MEASURES: A questionnaire was formulated containing the reasons for choosing a foundation programme with students asked to rank their choices. RESULTS: There were 46 replies. The most important factors identified were geographical location (score 154) and combination of specialties (score 178). The least important factors was the reputation of consultants (score 525) and opportunities for research (score 530). CONCLUSIONS: The factors influencing choice of foundation programme are not dissimilar to the choice of PRHO year despite the different emphasis in training which it offers.

The effects of a non-operative multimodal programme on osteoarthritis of the knee.

INTRODUCTION: The purpose of this study was to determine if a multimodal programme including physiotherapy and education could improve the symptoms of osteoarthritis of the knee across various severities of disease. PATIENTS AND METHODS: Seventy-two patients with osteoarthritis of the knee confirmed on radiographic evidence were referred over a 13-month period for a lower limb programme which consisted of 12 classes over 6 weeks of group physiotherapy and included education on osteoarthritis, diet and exercise. Six patients went on to have joint arthroplasty at a mean time of 6.5 months with three placed on the waiting list during follow-up. RESULTS: Pre-intervention, the mean WOMAC score was 42.0 and the mean Oxford Knee Score was 32.8. Post-intervention at a mean follow-up of 12 months, the mean WOMAC score was 31.6 and the mean Oxford Knee Score 24.3. The change in scores following intervention was statistically significant (P < 0.01). Using the WOMAC scoring system, the greatest effect size was seen in patients with Kellgren-Lawrence grade IV whilst using the Oxford knee scoring system, the greatest effect size was seen in patients with Kellgren-Lawrence grade II. CONCLUSIONS: At 12 months, a multimodal programme of non-operative interventions has an excellent impact upon the symptoms of osteoarthritis of the knee with improved patient-reported scores. The level of improvement cannot be inferred from the radiographic grade of osteoarthritis. This modality could be considered for all patients with mild-to-moderate osteoarthritis of the knee.

Primary gastric Hodgkin's lymphoma.

BACKGROUND: Primary Hodgkin's disease of the stomach is an extremely rare entity. Nearly all cases of primary gastric lymphoma are of the non-Hodgkin's variety. Diagnoses in such cases are difficult due to considerable histological similarities between the 2 disease entities. CASE PRESENTATION: We report the case of a 77 year old lady with a 1 year history of weight loss and poor appetite. Physical examination was unremarkable. Subsequent multiple upper GI endoscopies revealed a large malignant looking ulcer which was deemed to be histologically benign. Following CT imaging the patient underwent a radical gastrectomy. Postoperatively histology and immunohistochemistry failed to confirm a diagnosis. As such a second opinion was sought. Employing an extended array of immunohistological staining a diagnosis of 'Classical Hodgkin's' disease of the stomach was achieved. CONCLUSION: Our case illustrates the significant difficulties in achieving a rare diagnosis of primary Hodgkin's lymphoma of the stomach. The non-specific nature of symptoms and a lack of histological features make a preoperative diagnosis extremely difficult. While immunohistochemistry is widely employed in aiding the evaluation of such cases, one should be wary of the considerable overlap in differentiating between Hodgkin's and non-Hodgkin's disease entities using this technique.