Comparison of acute outcomes from elective total hip replacements and after fragility femoral neck fractures in nonagenarians.

BACKGROUND: Hip hemiarthroplasty has traditionally been used to treat displaced femoral neck fractures in older, frailer patients whilst total hip replacements (THR) have been reserved for younger and fitter patients. However, not all elderly patients are frail, and some may be able to tolerate and benefit from an acute THR. Nonagenarians are a particularly heterogenous subpopulation of the elderly, with varying degrees of independence. Since THRs are performed electively as a routine treatment for osteoarthritis in the elderly, its safety is well established in the older patient. The aim of this study was to compare the safety of emergency THR to elective THR in nonagenarians. METHODS: A retrospective 10-year cohort study was conducted using data submitted to the National Hip Fracture Database (NHFD) across three hospitals in one large NHS Trust. Data was collected from 126 nonagenarians who underwent THRs between 1st January 2010 - 31st December 2020 and was categorised into emergency THR and elective THR groups. Mortality rates were compared between the two groups. Secondary outcomes were also compared including postoperative complications (dislocations, revision surgeries, and periprosthetic fracture), length of stay in hospital, and discharge destination. RESULTS: There was no significant difference in mortality between the two groups, with 1-year mortality rates of 11.4% and 12.1% reported for emergency and elective patients respectively (p = 0.848). There were no significant differences in postoperative complication rate and discharge destination. Patients who had emergency THR spent 5.56 days longer in hospital compared to elective patients (p = 0.015). CONCLUSION: There is no increased risk of 1-year mortality in emergency THR compared to elective THR, in a nonagenarian population. Therefore, nonagenarians presenting with a hip fracture who would have been considered for a THR if presenting on an elective basis should not be precluded from an emergency THR on safety grounds. TRIAL REGISTRATION: Not necessary as this was deemed not to be clinical research, and was considered to be a service evaluation.

Predictors for Prolonged Hospital Stay Solely to Complete Intravenous Antifungal Treatment in Patients with Candidemia: Results from the ECMM Candida III Multinational European Observational Cohort Study.

BACKGROUND: To date, azoles represent the only viable option for oral treatment of invasive Candida infections, while rates of azole resistance among non-albicans Candida spp. continue to increase. The objective of this sub-analysis of the European multicenter observational cohort study Candida III was to describe demographical and clinical characteristics of the cohort requiring prolonged hospitalization solely to complete intravenous (iv) antifungal treatment (AF Tx). METHODS: Each participating hospital (number of eligible hospitals per country determined by population size) included the first ~ 10 blood culture proven adult candidemia cases occurring consecutively after July 1st, 2018, and treating physicians answered the question on whether hospital stay was prolonged only for completion of intravenous antifungal therapy. Descriptive analyses as well as binary logistic regression was used to assess for predictors of prolonged hospitalization solely to complete iv AF Tx. FINDINGS: Hospital stay was prolonged solely for the completion of iv AF Tx in 16% (100/621) of candidemia cases by a median of 16 days (IQR 8 - 28). In the multivariable model, initial echinocandin treatment was a positive predictor for prolonged hospitalization to complete iv AF Tx (aOR 2.87, 95% CI 1.55 - 5.32, p < 0.001), while (i) neutropenia, (ii) intensive care unit admission, (iii) catheter related candidemia, (iv) total parenteral nutrition, and (v) C. parapsilosis as causative pathogen were found to be negative predictors (aOR 0.22 - 0.45; p < 0.03). INTERPRETATION: Hospital stays were prolonged due to need of iv AF Tx in 16% of patients with candidemia. Those patients were more likely to receive echinocandins as initial treatment and were less severely ill and less likely infected with C. parapsilosis.

Quotation errors related to the wound management of open lower limb fractures (WOLLF) randomized clinical trial.

PURPOSE: We assessed the accuracy of quotations in the published literature of the Wound Management of Open Lower Limb Fractures (WOLLF) Randomized Clinical Trial. METHODS: A literature search was performed to identify all citations of WOLLF from 2018 to 2021. Duplicate papers, non-English language papers, textbooks, technical tip videos, Ph.D. theses, and other grey literature were excluded from analysis. Eligible publications had their full text assessed by 2 independent reviewers who used a validated framework of error classification. RESULTS: We identified 62 original papers that met our eligibility criteria and referenced WOLLF. Of the 62 papers, 12 contained a quotation error (12/62, 19%). Errors were classified into major and minor. There were 7 major errors and 5 minor errors. The majority of quotation errors (7/12, 58%) occurred due to multi-referencing, where groups of references were used to support single assertions. There was substantial agreement between the two independent reviewers as determined by a Kappa coefficient of 0.761. CONCLUSION: Our study demonstrated a 19% quotation error rate in the literature regarding WOLLF. The majority were due to multi-referencing. We suggest that both authors and reviewers carefully check the source literature of key references.

Medium-term mortality after hip fractures and COVID-19: A prospective multi-centre UK study.

PURPOSE: The COVID-19 pandemic has caused 1.4 million deaths globally and is associated with a 3-4 times increase in 30-day mortality after a fragility hip fracture with concurrent COVID-19 infection. Typically, death from COVID-19 infection occurs between 15 and 22 days after the onset of symptoms, but this period can extend up to 8 weeks. This study aimed to assess the impact of concurrent COVID-19 infection on 120-day mortality after a fragility hip fracture. METHODS: A multi-centre prospective study across 10 hospitals treating 8% of the annual burden of hip fractures in England between 1st March and 30th April, 2020 was performed. Patients whose surgical treatment was payable through the National Health Service Best Practice Tariff mechanism for "fragility hip fractures" were included in the study. Patients' 120-day mortality was assessed relative to their peri-operative COVID-19 status. Statistical analysis was performed using SPSS version 27. RESULTS: A total of 746 patients were included in this study, of which 87 (11.7%) were COVID-19 positive. Mortality rates at 30- and 120-day were significantly higher for COVID-19 positive patients relative to COVID-19 negative patients (p < 0.001). However, mortality rates between 31 and 120-day were not significantly different (p = 0.107), 16.1% and 9.4% respectively for COVID-19 positive and negative patients, odds ratio 1.855 (95% CI 0.865-3.978). CONCLUSION: Hip fracture patients with concurrent COVID-19 infection, provided that they are alive at day-31 after injury, have no significant difference in 120-day mortality. Despite the growing awareness and concern of "long-COVID" and its widespread prevalence, this does not appear to increase medium-term mortality rates after a hip fracture.

Thompson Hemiarthroplasty for Femoral Neck Fracture Is Associated With Increased Risk of Dislocation.

BACKGROUND: This contemporaneous large multicenter retrospective study reflective of current practice, assesses the impact of patient factors, prosthesis selection, and implant features on the risk of dislocation after hip hemiarthroplasty for femoral neck fracture. METHODS: Radiographic records for 4116 consecutive patients who underwent a hip hemiarthroplasty between January 1, 2009 and September 30, 2017 at 3 acute hospitals (including a regional major trauma center) for a neck of femur fracture were reviewed in conjunction with United Kingdom National Hip Fracture Database records. RESULTS: In total, 4116 patients were eligible for inclusion in the study; 63 of 4116 (1.5%) dislocations were identified. Patient age, gender, preoperative abbreviated mental test score, postoperative abbreviated mental test score, and American Society of Anaesthesiologists grade were not found to be significant predictors of dislocation rates (P < .05). The Furlong prosthesis was the most commonly used implant (2280/4116, 55.4%) followed by the Exeter V40 + Unitrax head (1179/4116, 28.6%), other implants used during the study period were the monoblock Austin-Moore and Thompson implants. Hemiarthroplasty operations undertaken with the Thompson (24/273, 3.7%) were found to have significantly higher dislocation rates (P < .05). Cemented vs uncemented, variable vs fixed offset, and monoblock vs modular implant designs did not contribute to higher dislocation rates (P < .05). Surgeon seniority was also not a significant risk factor for subsequent dislocation (P < .05). CONCLUSIONS: Thompson hip hemiarthroplasties are associated with higher dislocation rates when compared to a contemporaneous cohort of implant choices and considerations for their use should be made in conjunction with this major risk factor for the need for subsequent operations.

Learning curves in surgery: variables, analysis and applications.

Learning curves graphically represent the relationship between learning effort and learning outcome. Learning curves are increasingly used in research, the design of randomised controlled trials, the assessment of competency, healthcare education and training programme design. In this review we have outlined the principles behind plotting learning curves, described the common methods used to analyse learning curves, how to interpret learning curves, the multitude of learning models, their applications and potential pitfalls, and the importance of a mathematically rigorous approach to learning curve analytics.

Cement augmentation of the acetabulum for revision total hip arthroplasty for infection.

Antibiotic-loaded cement spacers in first-stage revision hip arthroplasty for infection are associated with a high dislocation and fracture rate. This technical note describes a novel surgical technique, utilizing screws and cement, improving acetabular coverage and reducing the risk of mechanical failure. Fifteen infected hip prostheses underwent removal, cement acetabular augmentation and insertion of a femoral cement spacer. Eleven hips had successful infection eradication and subsequently underwent a second stage revision procedure a mean duration of 15 weeks (9-48) after the first stage. No dislocations or fractures of the cement spacers were observed. This technique affords the potential to reduce the duration of time cement spacers remaining in situ, provides enhanced mechanical stability and improved antibiotic elution through cement-on-cement articulation.

The results of total hip arthroplasty for fractured neck of femur in octogenarians.

The role of total hip arthroplasty (THA) for fracture in octogenarians remains unclear. Over a two-year period, 354 patients aged > 80 years were admitted with a displaced intracapsular hip fracture. Using defined clinical guidelines, 38 patients underwent THA with a median age of 84 years, mean follow-up of 20 months. Primary outcomes were dislocation, 30-day and one-year mortality, revision surgery and periprosthetic fracture. There were no dislocations or periprosthetic fractures and patient survival was 97% at 30 days and 87% at one year. There was one revision for deep infection. This study demonstrates that THA for selected octogenarians can be performed safely, allows the majority of patients to return to independent living and has a low complication rate.

Patient-reported compliance with thromboprophylaxis using an oral factor Xa inhibitor (rivaroxaban) following total hip and total knee arthroplasty.

This prospective study examines patient non-compliance (NC) for an oral factor Xa inhibitor (Rivaroxaban) when used as venous thromboembolic (VTE) prophylaxis following lower limb arthroplasty. A total of 3145 patients underwent surgery from May 2010 to December 2011. At 6 weeks patients completed an anonymous self-administered questionnaire. Postoperatively 2947 (94%, 2947/3145) received Rivaroxaban. 2824 (96%, 2824/2947) completed all in-hospital doses. Seven percent (203/2824) of patients did not attend the 6-week follow-up. Two thousand one hundred sixty-three (83%, 2163/2621) completed all prescribed doses, 98 (4%, 98/2621) were NC and 360 (14%, 360/2621) had incomplete data. Gender, age, body mass index and preoperative hemoglobin all correlated with NC (p < 0.05). Type and side of surgery did not correlate with compliance (p > 0.05). Patient-reported NC for Rivaroxaban is 4% which compares favorably to other VTE prophylaxis modalities.

Modelling of longitudinally cut carrot curling induced by the vascular cylinder-cortex interference pressure.

Cut carrot pieces are popular convenience foods, which enable the use of misshapen or physiologically imperfect produce. Cut carrots curl due to residual stress, which limits their shelf life and causes unnecessary food waste. The aim of this study is to identify the geometrical and environmental factors which have the most influence on their longevity. An analytical equation was developed using compound cylinder solutions, and this was used to define carrot-specific finite element (FE) models. Over 100 longitudinally cut Lancashire Nantes carrot halves were characterized, each was modelled analytically and verified using FE models. This model was evaluated by comparing predicted curvatures to ones experimentally measured over a week. The average radius of curvature decreased from 1.61 to 1.1 m a week after. A 1.32× reduction in the elastic modulus after 7 days was observed. The moisture content reduction relates to 22% weight loss, correlating to the decreasing radius of curvature. Subsequently, carrots are recommended to be stored in humidity-controlled environments. The experimental results from this study match the predictions made using mechanical principles. The research provides a methodology to predict the deformation of cut root vegetables, and the procedure is likely to be applicable to other plant structures.

Guideline adherence and survival of patients with candidaemia in Europe: results from the ECMM Candida III multinational European observational cohort study.

BACKGROUND: The European Confederation of Medical Mycology (ECMM) collected data on epidemiology, risk factors, treatment, and outcomes of patients with culture-proven candidaemia across Europe to assess how adherence to guideline recommendations is associated with outcomes. METHODS: In this observational cohort study, 64 participating hospitals located in 20 European countries, with the number of eligible hospitals per country determined by population size, included the first ten consecutive adults with culture-proven candidaemia after July 1, 2018, and entered data into the ECMM Candida Registry (FungiScope CandiReg). We assessed ECMM Quality of Clinical Candidaemia Management (EQUAL Candida) scores reflecting adherence to recommendations of the European Society of Clinical Microbiology and Infectious Diseases and the Infectious Diseases Society of America guidelines. FINDINGS: 632 patients with candidaemia were included from 64 institutions. Overall 90-day mortality was 43% (265/617), and increasing age, intensive care unit admission, point increases in the Charlson comorbidity index score, and Candida tropicalis as causative pathogen were independent baseline predictors of mortality in Cox regression analysis. EQUAL Candida score remained an independent predictor of mortality in the multivariable Cox regression analyses after adjusting for the baseline predictors, even after restricting the analysis to patients who survived for more than 7 days after diagnosis (adjusted hazard ratio 1·08 [95% CI 1·04-1·11; p<0·0001] in patients with a central venous catheter and 1·09 [1·05-1·13; p<0·0001] in those without one, per one score point decrease). Median duration of hospital stay was 15 days (IQR 4-30) after diagnosis of candidaemia and was extended specifically for completion of parenteral therapy in 100 (16%) of 621 patients. Initial echinocandin treatment was associated with lower overall mortality and longer duration of hospital stay among survivors than treatment with other antifungals. INTERPRETATION: Although overall mortality in patients with candidaemia was high, our study indicates that adherence to clinical guideline recommendations, reflected by higher EQUAL Candida scores, might increase survival. New antifungals, with similar activity as current echinocandins but with longer half-lives or oral bioavailability, are needed to reduce duration of hospital stay. FUNDING: Scynexis.

European candidaemia is characterised by notable differential epidemiology and susceptibility pattern: Results from the ECMM Candida III study.

The objectives of this study were to assess Candida spp. distribution and antifungal resistance of candidaemia across Europe. Isolates were collected as part of the third ECMM Candida European multicentre observational study, conducted from 01 to 07-07-2018 to 31-03-2022. Each centre (maximum number/country determined by population size) included ∼10 consecutive cases. Isolates were referred to central laboratories and identified by morphology and MALDI-TOF, supplemented by ITS-sequencing when needed. EUCAST MICs were determined for five antifungals. fks sequencing was performed for echinocandin resistant isolates. The 399 isolates from 41 centres in 17 countries included C. albicans (47.1%), C. glabrata (22.3%), C. parapsilosis (15.0%), C. tropicalis (6.3%), C. dubliniensis and C. krusei (2.3% each) and other species (4.8%). Austria had the highest C. albicans proportion (77%), Czech Republic, France and UK the highest C. glabrata proportions (25-33%) while Italy and Turkey had the highest C. parapsilosis proportions (24-26%). All isolates were amphotericin B susceptible. Fluconazole resistance was found in 4% C. tropicalis, 12% C. glabrata (from six countries across Europe), 17% C. parapsilosis (from Greece, Italy, and Turkey) and 20% other Candida spp. Four isolates were anidulafungin and micafungin resistant/non-wild-type and five resistant to micafungin only. Three/3 and 2/5 of these were sequenced and harboured fks-alterations including a novel L657W in C. parapsilosis. The epidemiology varied among centres and countries. Acquired echinocandin resistance was rare but included differential susceptibility to anidulafungin and micafungin, and resistant C. parapsilosis. Fluconazole and voriconazole cross-resistance was common in C. glabrata and C. parapsilosis but with different geographical prevalence.

Proximal femoral allograft in revision hip surgery with severe femoral bone loss: a systematic review and meta-analysis.

This study provides an objective appraisal of available evidence regarding the outcome of proximal femoral allograft for reconstruction of massive proximal femoral bone loss. The primary outcomes were rates of success, structural failure, and infection. A systematic literature review identified 16 studies with a minimum 2-year follow-up. Estimated pooled effect analysis performed with heterogeneity quantified using I(2) and τ(2). The total cohort included 498 patients with a mean follow-up of 8.1 years. The pooled success rate was 81%, pooled structural failure rate of 15%, and pooled infection rate of 8%. Significant heterogeneity was observed in structural failure rates (I(2) = 47.9, τ(2) = 0.29, P < .05). Proximal femoral allografts afford viable reconstruction for massive femoral bone loss when performed by experienced.

The reconstruction of periprosthetic pelvic discontinuity.

The surgical techniques and outcomes of acetabular reconstruction for periprosthetic pelvic discontinuity cases are reported. The mean time to surgery for 9 patients with acute pelvic discontinuity was 16.3 days, with 8 patients (88%) having posterior column plating and a porous metal acetabular cup. No cases required revision surgery, with a mean follow-up of 34 months (range, 24-67 months). Of the 62 chronic pelvic discontinuity cases, 20 had an ilioischial cage, with a revision rate of 29%. There were 42 cup-cage reconstructions with an 8-year survivorship of 86.3%, with a mean follow-up of 35 months (range, 24-93 months). Stable reconstruction of chronic pelvic discontinuity was achievable by distraction using a cup-cage acetabular reconstruction; however, satisfactory stability of acute pelvic discontinuity was achieved with compression of the posterior column using screw augmentation of the acetabular shell supplemented by posterior column plating.

Predicting 30-day mortality after hip fracture: the G4A calibrated prognostic tool.

INTRODUCTION: Proximal femoral fracture is common with a high mortality (7% mortality at 30 days). Accurate determination of mortality risk allows better consenting, clinical management and expectation management. Our study aim was to develop a prognostic tool to predict 30-day mortality after proximal femoral fracture, among patients treated within a dedicated hip fracture unit. MATERIALS AND METHODS: We collected data from our hospital concerning 2210 patients with 2287 proximal femoral fractures. The clinical parameters of 97 patients who died within 30 days of surgery were analysed. We used logistic regression to determine if the parameters' relationship with 30-day mortality was statistically significant or not. The statistically significant parameters were used to create a prognostic model for predicting 30-day mortality. RESULTS: The 5 independent predictors of 30-day mortality were gender, age, admission source, preoperative Abbreviated Mental Test Score (AMTS) and American Society of Anesthesiologists Score (ASA). The highest risk was for males >85 years, admitted from institutional care, with low preoperative mental test score and high ASA grade. Using these predictors, we formulated the G4A score. The Hosmer-Lemeshow 'goodness of fit' test showed good concordance between observed and predicted mortality rates. CONCLUSIONS: We recommend the use of the G4A score to predict 30-day mortality after surgery for proximal femoral fracture, particularly within dedicated hip fracture units. Further research is needed to establish whether the findings of this study are applicable on a national scale.

Sequential outcome following autologous chondrocyte implantation of the knee: a six-year follow-up.

This prospective six-year longitudinal study reviews the clinical outcome of patients undergoing autologous chondrocyte implantation (ACI) and a porcine type I/III collagen membrane cover for deep chondral defects of the knee. We present 57 patients (31 male, 26 female) with a mean age of 31.6 years (range 15-51 years) that have undergone ACI since July 1998. The mean size of the defect was 3.14 cm(2) (range 1.0-7.0 cm(2)). All patients were assessed annually using seven independent validated clinical rating scores with the data analysed using ANOVA. ACI using a porcine type I/III collagen membrane cover produced statistically significant improvements (p < 0.001), maintained for up to six years, in knee symptoms compared to pre-operative levels. This study provides evidence of the medium-term benefit achieved by transplanting autologous chondrocytes to osteochondral defects.

Review of smoothed particle hydrodynamics: towards converged Lagrangian flow modelling.

This paper presents a review of the progress of smoothed particle hydrodynamics (SPH) towards high-order converged simulations. As a mesh-free Lagrangian method suitable for complex flows with interfaces and multiple phases, SPH has developed considerably in the past decade. While original applications were in astrophysics, early engineering applications showed the versatility and robustness of the method without emphasis on accuracy and convergence. The early method was of weakly compressible form resulting in noisy pressures due to spurious pressure waves. This was effectively removed in the incompressible (divergence-free) form which followed; since then the weakly compressible form has been advanced, reducing pressure noise. Now numerical convergence studies are standard. While the method is computationally demanding on conventional processors, it is well suited to parallel processing on massively parallel computing and graphics processing units. Applications are diverse and encompass wave-structure interaction, geophysical flows due to landslides, nuclear sludge flows, welding, gearbox flows and many others. In the state of the art, convergence is typically between the first- and second-order theoretical limits. Recent advances are improving convergence to fourth order (and higher) and these will also be outlined. This can be necessary to resolve multi-scale aspects of turbulent flow.