Fatal pulmonary embolism following elective total knee replacement using aspirin in multi-modal prophylaxis - A 12year study.

BACKGROUND: The National Institute for Health and Clinical Excellence (NICE) has issued guidelines on which thromboprophylaxis regimens are suitable following lower limb arthroplasty. Aspirin is not a recommended agent despite being accepted in orthopaedic guidelines elsewhere. We assessed the incidence of fatal pulmonary embolism (PE) and all-cause mortality following elective primary total knee replacement (TKR) with a standardised multi-modal prophylaxis regime in a large teaching district general hospital. METHODS: We utilised a prospective audit database to identify those that had died within 42 and 90days postoperatively. Data from April 2000 to 2012 were analysed for 42 and 90day mortality rates. There were a total of 8277 elective primary TKR performed over the 12year period. The multi-modal prophylaxis regimen used unless contraindicated for all patients included 75mg aspirin once daily for four weeks. Case note review ascertained the causes of death. Where a patient had been referred to the coroner, they were contacted for post mortem results. RESULTS: The mortality rates at 42 and 90days were 0.36 and 0.46%. There was one fatal PE within 42days of surgery (0.01%) who was taking enoxaparin because of aspirin intolerance. Two fatal PE's occurred at 48 and 57days post-operatively (0.02%). The leading cause of death was myocardial infarction (0.13%). CONCLUSIONS: Fatal PE following elective TKR with a multi-modal prophylaxis regime is a very rare cause of mortality.

The effect of surgical experience on the amount of radiation exposure from fluoroscopy during dynamic hip screw fixation.

INTRODUCTION Dynamic hip screw (DHS) fixation for proximal femur fractures is one of the most common procedures in trauma that requires the use of fluoroscopy. Emphasis is often placed on producing the 'perfect picture', which may lead to excessive use of fluoroscopy, without added patient benefit. This study, the largest of its kind, aimed to determine the effect of surgical experience on the amount of radiation exposure from fluoroscopy during DHS fixation. METHODS All hospital admissions for extracapsular proximal femur fractures to our institution between 2007 and 2012 were analysed. Patient demographics, fracture configuration, grade of surgeon and the total radiation dose after fixation were recorded. Analysis of variance was performed to assess differences in radiation levels between different grades of surgeon. RESULTS A total of 1,203 patients with a mean age of 81.3 years (range: 21-105 years) were included in the study. The majority of the fractures were three-part (33.3%), followed by two-part (32.2%), four-part (25.7%) and basicervical (8.9%). Registrars (ST3-ST8) used a significantly higher radiation dose than consultants for all fracture types (p=0.009). When analysed separately by trainee group, the most junior registrars (ST3-ST4) and the most senior registrars (ST7-ST8) were found to use significantly higher radiation levels than consultants (p=0.037 and p<0.001 respectively). CONCLUSIONS The level of surgical experience does influence the amount of radiation exposure from fluoroscopy during DHS fixation. Surgical trainees should not ignore the potential harmful effects of radiation and should be equipped with the knowledge of how to keep the radiation exposure as low as possible.

Long term survivorship following Scorpio Total Knee Replacement.

BACKGROUND: The Scorpio Total Knee Replacement (TKR) is one of the most commonly used prosthesis in the United Kingdom. Concerns arose at our institution that there was a high revision rate for this prosthesis. No study has assessed survivorship of this prosthesis over 10 years. METHODS: Four hundred and fifty-six consecutive patients, who underwent a primary Scorpio TKR, were clinically and radiologically evaluated. WOMAC, Oxford Knee Score and all complications including the reason for revision surgery were recorded. The Knee Society Roentgenographic Evaluation and Scoring System was used to evaluate all radiographs for prosthesis alignment and degree of subsequent lucency. Survival analysis for the prosthesis was calculated using Kaplan-Meier curves, with revision as an end-point. Patient reported outcome measures were compared against radiographic evaluation. RESULTS: At a mean of 12.5 years (range 10-14 years), 196 (43.0%) patients were available for review; 124 (27.2%) were lost to follow-up and 136 (29.8%) patients had died of unrelated causes. Seven (3.6%) patients required revision surgery at a mean of 5.4 years; five because of aseptic loosening and two because of septic loosening. Cumulative survival for the prosthesis was 99.5% for any cause at five years and 97.4% at 14 years. The mean OKS and WOMAC score at final follow-up was 30.64 (range 12-48) and 74 (18.9-100) respectively. CONCLUSION: The Scorpio TKR has good long term survivorship and functional outcomes. There is no apparent increased revision rate for this prosthesis in our study. LEVEL OF EVIDENCE: Level IV case series.

Obesity and recurrent intervertebral disc prolapse after lumbar microdiscectomy.

INTRODUCTION: The primary aim of this study was to investigate the relationship between obesity and recurrent intervertebral disc prolapse (IDP) following lumbar microdiscectomy. METHODS: A retrospective review of case notes from 2008 to 2012 was conducted for all patients who underwent single level lumbar microdiscectomy performed by a single surgeon. All patients were followed up at two weeks and six weeks following surgery, and given an open appointment for a further six months. RESULTS: A total of 283 patients were available for analysis: 190 (67%) were in the non-obese group and 93 (32.9%) in the obese group. There was no statistical difference in postoperative infection, dural tear or length of stay between the non-obese and obese groups. Recurrent symptomatic IDP was seen in 27 patients (9.5%) confirmed by magnetic resonance imaging. Nineteen (10.0%) were in the non-obese group and eight (8.6%) in the obese group (p>0.8). CONCLUSIONS: In our study, obesity was not a predictor of recurrent IDP following lumbar microdiscectomy. Our literature review confirmed that this study reports the largest series to date analysing the relationship between obesity and recurrent IDP following lumbar microdiscectomy in the British population.

Long-term survivor characteristics in HER2-positive metastatic breast cancer from registHER.

BACKGROUND: Data characterising long-term survivors (LTS) with human epidermal growth factor receptor 2 (HER2)-positive metastatic breast cancer (MBC) are limited. This analysis describes LTS using registHER observational study data. METHODS: A latent class modelling (LCM) approach was used to identify distinct homogenous patient groups (or classes) based on progression-free survival (PFS), overall survival, and complete response. Demographics, clinicopathologic factors, first-line treatment patterns, and clinical outcomes were described for each class. Class-associated factors were evaluated using logistic regression analysis. RESULTS: LCM identified two survivor groups labelled as LTS (n=244) and short-term survivors (STS; n=757). Baseline characteristics were similar between groups, although LTS were more likely to be white (83.6% vs 77.8%) with oestrogen receptor-positive (ER+) or progesterone receptor-positive (PgR+) disease (59.4% vs 50.9%). Median PFS in LTS was 37.2 (95% confidence interval (CI): 32.9-40.5) vs 7.3 months (95% CI: 6.8-8.0) in STS. Factors associated with long-term survival included ER+ or PgR+ disease, metastasis to node/local sites, first-line trastuzumab use, and first-line taxane use. CONCLUSIONS: Prognostic variables identified by LCM define a HER2-positive MBC patient profile and therapies that may be associated with more favourable long-term outcomes, enabling treatment selection appropriate to the patient's disease characteristics.

Incidence of central nervous system metastases in patients with HER2-positive metastatic breast cancer treated with pertuzumab, trastuzumab, and docetaxel: results from the randomized phase III study CLEOPATRA.

BACKGROUND: Results from the phase III trial CLEOPATRA in human epidermal growth factor receptor 2-positive first-line metastatic breast cancer demonstrated significant improvements in progression-free and overall survival with pertuzumab, trastuzumab, and docetaxel over placebo, trastuzumab, and docetaxel. We carried out exploratory analyses of the incidence and time to development of central nervous system (CNS) metastases in patients from CLEOPATRA. PATIENTS AND METHODS: Patients received pertuzumab/placebo: 840 mg in cycle 1, then 420 mg; trastuzumab: 8 mg/kg in cycle 1, then 6 mg/kg; docetaxel: initiated at 75 mg/m(2). Study drugs were administered i.v. every 3 weeks. The log-rank test was used for between-arm comparisons of time to CNS metastases as first site of disease progression and overall survival in patients with CNS metastases as first site of disease progression. The Kaplan-Meier approach was used to estimate median time to CNS metastases as first site of disease progression and median overall survival. RESULTS: The incidence of CNS metastases as first site of disease progression was similar between arms; placebo arm: 51 of 406 (12.6%), pertuzumab arm: 55 of 402 (13.7%). Median time to development of CNS metastases as first site of disease progression was 11.9 months in the placebo arm and 15.0 months in the pertuzumab arm; hazard ratio (HR) = 0.58, 95% confidence interval (CI) 0.39-0.85, P = 0.0049. Overall survival in patients who developed CNS metastases as first site of disease progression showed a trend in favor of pertuzumab, trastuzumab, and docetaxel; HR = 0.66, 95% CI 0.39-1.11. Median overall survival was 26.3 versus 34.4 months in the placebo and pertuzumab arms, respectively. Treatment comparison of the survival curves was not statistically significant for the log-rank test (P = 0.1139), but significant for the Wilcoxon test (P = 0.0449). CONCLUSIONS: While the incidence of CNS metastases was similar between arms, our results suggest that pertuzumab, trastuzumab, and docetaxel delays the onset of CNS disease compared with placebo, trastuzumab, and docetaxel. CLINICALTRIALSGOV: NCT00567190.

The influence of socioeconomic status on the incidence, outcome and mortality of fractures of the hip.

This is the first study to use the English Indices of Multiple Deprivation 2007, the Government's official measure of multiple deprivation, to analyse the effect of socioeconomic status on the incidence of fractures of the hip and their outcome and mortality. Our sample consisted of all patients admitted to hospital with a fracture of the hip (n = 7511) in Nottingham between 1999 and 2009. The incidence was 1.3 times higher (p = 0.038) in the most deprived populations than in the least deprived; the most deprived suffered a fracture, on average, 1.1 years earlier (82.0 years versus 83.1 years, p < 0.001). The mortality rate proved to be significantly higher in the most deprived population (log-rank test, p = 0.033), who also had a higher number of comorbidities (p = 0.001). This study has shown an increase in the incidence of fracture of the hip in the most deprived population, but no association between socioeconomic status and mortality at 30 days. Preventative programmes aimed at reducing the risk of hip fracture should be targeted towards the more deprived if they are to make a substantial impact.

Judet decortication and compression plate fixation of long bone non-union: Is bone graft necessary?

Non-union occurs in 5-10% of all fractures and is caused by a variety of mechanical and biological factors. Stable fixation is essential and many authors recommend the addition of bone graft. Our aim was to evaluate the results of internal fixation using Judet decortication and compression plating for long bone fractures and assess the impact of bone grafting on union rates. Our study group comprised all the patients undergoing compression plate fixation under a single surgeon over a fourteen year period (n=96). AO principles were used and the standard technique involved Judet decortication, compression plating and lag screws. Autologous bone graft was harvested from the iliac crest. The mean age was 45 years and 62% were male. The fracture site was the clavicle (n=20); humerus (n=23); radius and ulna (n=5); femur (n=31) and tibia (n=17). The primary fracture treatment was non-operative (n=41); IM nail (n=22); plate fixation (n=28) and external fixation (n=5). Deep infection was present in 6 cases. Bone graft was used in 40 cases. 91/96 non-unions treated with compression plating healed (95%). Bone grafting was used in all cases for the initial part of the series but its use declined as the surgeon became more confident that the non-unions would heal without the use of bone graft. The case mix and complexity remained constant throughout the study period and the union rate also remained constant. The mean time to radiological union was 6.4 months. In those treated with a compression plate without bone graft the union rate was 94.6% whilst the addition of bone graft resulted in a union rate of 95% (p=0.67). From our study we concluded that the routine use of autologous bone graft may not be necessary and, based upon the union rates observed in this study, a prospective randomised study to evaluate the use of bone graft in non-union surgery would need a sample size of 194,000 to detect a significant increase in union with 80% power. In terms of Numbers Needed Treat (NNT), we would need to give 1179 patients a bone graft to prevent one additional failure of healing.