The Accuracy of Digital Preoperative Templating in Primary Total Hip Replacements.

Background​ Digital templating is an essential part of preoperative planning in elective total hip replacement (THR) surgery. The goals of templating are to predict femoral and acetabular implant sizes, to assess leg length, offset, and implant positioning. Templating markers such as the KingMark device (Brainlab, Munich, Germany) have been developed to improve the accuracy. Although templating is commonly used in many centres, there are challenges related to the accuracy of the process, such as true magnification ideal positioning of the pelvis and hips/body habit (obesity). Objectives The aim of this study was to assess the accuracy of preoperative templating in THR patients, and to assess the difference between templating performed with and without the KingMark device. Methods​ Our retrospective study included 642 consecutive patients who had primary THR at the Royal Bournemouth Hospital in the UK. Four hundred fifty-three (71%) of patients had the KingMark device on their templated radiographs. Patients who had hybrid total hip replacements using an uncemented acetabular component and cemented femoral component were included in the study. Digital templating was done using TraumaCad software (Brainlab). Analysis of the accuracy of predicting component size has been evaluated by comparing preoperative planned sizes with implanted sizes as documented by the surgeons and labels attached to the operative note. ​ ​Results​ The templated size corresponded to the actual femoral implant used in approximately 65.2% of cases. When femoral prostheses within one size above or below the templated size were included,​the accuracy of preoperative templating rose to 97.2%. Regarding the uncemented acetabular component, the templated size corresponded to the actual acetabular implant used in 46.3% of cases. When acetabular cup within one size above or below the templated size were included, the accuracy of preoperative templating rose to 87.5%. Similarly, there was minimal difference between the predicted templated sizes using the KingMark device compared to templating performed without it. ​Conclusions​ Preoperative templating is an essential part in optimizing the outcome of THRs. Templating allows the surgeon to estimate the size of the components to be used. It also provides a starting point, from which the surgeon can proceed from, and saves valuable intraoperative time by assessing the level of the femoral neck osteotomy and the degree of lateral rasping. Multiple factors affect the accuracy of preoperative templating including the patient BMI, external rotation of the hip and surgeon's experience. Although there are different methods of templating, digital templating with 2D radiographs is likely the most cost-effective and efficient process available at this time.

A case of combined pulmonary vein isolation (PVI) and watchman implant through hepatic vein in a patient with interrupted inferior vena cava (IVC).

This case report describes a successful procedure involving pulmonary vein isolation (PVI) and left atrial appendage (LAA) closure with a watchman device in a 78-year-old male with atrial fibrillation and an interrupted inferior vena cava. Due to the vascular anomaly, a transhepatic approach was used, which proved successful.

Periprosthetic Fractures in Long Versus Short Proximal Femoral Nailing for Intertrochanteric Fractures: A 10-Year Single-Centre Cohort Study.

Background Neck of femur (NOF) fractures, including intertrochanteric fractures, are common fragility fractures seen in the elderly population and are often amenable to fixation with a proximal femoral nail (PFN). However, there is conflicting evidence regarding the incidence of peri-prosthetic fractures with each device. Several studies from the 1990s and a recent meta-analysis have shown a higher incidence of peri-prosthetic fractures in the short PFN cohort. Other studies have shown a lower reoperation rate with short PFNs, and no statistically significant differences have been quoted in the rates of peri-prosthetic fractures in systematic reviews. Aim The purpose of this retrospective study, therefore, was to assess the peri-prosthetic fracture rate and failure rates of elderly neck of femur (NOF) fractures implanted with either a short or long proximal femoral nail (PFN). Materials and methods A retrospective study was conducted in a single orthopaedic department (University Hospital Dorset, Poole, GBR) using collected data on all extracapsular neck of femur fracture patients from the national hip fracture database (NHFD) from January 1, 2011, to December 23, 2021. The data collected included patient age, sex, the American Society of Anesthesiologists (ASA) type of neck of femur fracture, type of surgery performed, any further peri-prosthetic fractures, and time to re-operation in that subset of the group. The implants used were the Stryker Gamma 3 Nail and the Smith Nephew (Trigen and Intertan). All patients were allowed to fully weight bear as tolerated and received both orthopaedic and elderly medical care. Failure was defined as a cut-out or implant fracture. Results From January 1, 2011, to December 23, 2021, there were 1010 extracapsular neck of femur fractures recorded on the National Hip Fracture Database (NHFD) treated with a PFN from the study centre. Of those patients, 11 had pathological fractures and were excluded. 649 patients had long PFNs, and 350 had short PFNs. Of the total of 999 patients, 254 (25%) were male and 745 (75%) were female. More than 80% of the patients in the sample were over the age of 75. The majority of patients in both groups had A1/A2 fractures (short 84.3%, long 49.1%). The rate of periprosthetic fractures in the short PFNs was 1.71%, and the failure rate was 0.57%. The rate of periprosthetic fractures in the long PFNs was 0.62%, with a failure rate of 0.92%. The multi-nominal logistic regression model did not show statistically significant odds ratios (OR) for the following variables: long/short nails, male/female gender, age, ASA, or type of fracture. The female gender was associated with a higher risk of both periprosthetic fractures and failures (OR of 2.232 and 2.95), but this was not found to be statistically significant. Similarly, unstable A3 fractures had a much higher risk of failure (OR of 2.691) compared to periprosthetic fractures (OR of 0.985). However, this was not statistically significant. Conclusion Overall, this study has identified that in a patient population that is predominantly female and over the age of 75, the risk of periprosthetic fracture rate and the failure rate is similar in both the use of a short or a long PFN for intertrochanteric fractures.

Injection drug induced septic embolism-A growing concern.

Septic pulmonary embolism is an obstruction of the pulmonary vasculature due to embolization of an infected thrombus. In many instances, the etiology is cardiac in origin, given the increased prevalence of intravenous drug users in the United States. This condition usually presents with fever, chest pain, dyspnea, and cough. In order to make the diagnosis, it is helpful to utilize tools like the modified Duke criteria when evaluating for infective endocarditis in the context of pulmonary emboli and septic shock. The gold standard method for establishing the diagnosis of this condition involves imaging modalities, including echocardiogram and computed tomography findings. This case report details a 36-year-old male with a history of drug abuse and hepatitis C, who was found to have an isolated vegetation on the pulmonic valve and septic pulmonary embolism. The patient experienced a rapidly deteriorating clinical course, however improved over the course of 2 weeks with supportive measures and appropriate antibiotic treatment. The purpose of this case report is to highlight the uncommon nature of pulmonary valve involvement in patients with infective endocarditis. Moreover, the goal of this report is to recognize the paralleled increase in septic pulmonary emboli with the rising incidence of patients using injectable opioids in the United States.

Tularemia: The Resurgence of a Diagnostic Challenge and Clinical Dilemma in the United States.

Tularemia is a rare, life-threatening zoonotic infection with low, naturally occurring transmission rates in the United States. Classified as a Category A bioterrorism agent, this disease is highly infectious and has the potential to be fatal if left untreated. Making the diagnosis is difficult due to the non-specific symptomatology patients present with. Considering the increase in the prevalence of this diagnosis over the past two decades, this condition has the potential to become a public health crisis. This case report details a pediatric patient who was found to have fever, ulceration, and lymphadenopathy on hospital admission. After a prolonged and protracted course of illness, tularemia was diagnosed with laboratory testing. The purpose of this case report is to increase awareness of tularemia as a potential cause of non-specific flu-like symptoms, especially during the summer months. Moreover, our goal is to propose suggestions for healthcare professionals who encounter patients with clinical suspicion of tularemia.

Delayed Diagnosis of Cardiac Amyloidosis Secondary to Multiple Myeloma.

Cardiac amyloidosis is a rare condition with only 2,500 new cases reported yearly in the United States of America (USA). The prognosis of cardiac amyloidosis is particularly grim. The median survival is 6 months from onset of congestive heart failure (CHF) symptoms. CHF is a common presentation as the second leading cause of hospitalization in the senile population in the USA. We report a case of an 83-year-old man who presented with the classic symptoms of CHF including bilateral lower extremity edema, shortness of breath, and weight gain. Upon further workup, an echocardiogram revealed strain patterns suggestive of cardiac amyloidosis and bone marrow biopsy confirmed the diagnosis of multiple myeloma. Unfortunately, despite starting treatment with steroids and chemotherapy, the patient succumbed to his condition in a matter of weeks. We report this case to highlight that cardiac amyloidosis secondary to multiple myeloma can present in the form of new onset, quickly deteriorating CHF long before any classic multiple myeloma symptoms manifest.

Acquired Von Willebrand Syndrome (AVWS) in cardiovascular disease: a state of the art review for clinicians.

Von Willebrand Factor (vWF) is a large glycoprotein with a broad range of physiological and pathological functions in health and disease. While vWF is critical for normal hemostasis, vascular integrity and repair, quantitative and qualitative abnormalities in the molecule can predispose to serious bleeding and thrombosis. The heritable form of von Willebrand Disease was first described nearly a century ago, but more recently, recognition of an acquired condition known as acquired von Willebrand Syndrome (AVWF) has emerged in persons with hematological, endocrine and cardiovascular diseases, disorders and conditions. An in-depth understanding of the causes, diagnostic approach and management of AVWS is important for practicing clinicians.

Inflammation and coronary artery disease: from pathophysiology to Canakinumab Anti-Inflammatory Thrombosis Outcomes Study (CANTOS).

The worldwide prevalence of cardiovascular disease in general and atherosclerotic coronary artery disease in particular is a health and economic concern of unparalleled proportion. Despite a long history of astute observations beginning in 1575 made by Fallopius, followed by those of von Rokatansky, Virchow, Osler, and Ross, and incremental knowledge of the pathobiology of atherosclerosis to include varying stages of inflammation, response to internally and externally mediated vascular injury, and impaired homeostasis, gaps in the field's understanding persist. Here, we summarize the current scope of the problem for coronary artery disease, emerging constructs in its pathobiology and common clinical phenotypes, potentially useful biomarkers, clinical trials designed specifically to test the 'inflammation hypothesis' of disease, and the interface of pathobiology and precision medicine as a foundation for diagnosis, management, and future advances in the diagnosis, prognosis, natural history, prevention, and optimal management.