Day case ankle arthroplasty: are they safe and cost effective? A single-centre case-control study.

Background: Most patients who have an ankle replacement in the United Kingdom stay in hospital for 2-4 days. This study looked at the safety & cost-effectiveness of a day case ankle replacement pathway. Methods: This was a retrospective case-control study looking at day case pathway for ankle replacements set up in collaboration with anaesthetists, nurses and physiotherapists. Patients practiced mobilization with crutches before surgery. Patients were discharged home with enough analgesia, and reviewed within 2-5 days of discharge. Results: Twenty ankle replacements done between November 2017 and November 2019 were reviewed with a mean follow up of 38.4 months. None of these patients required to be readmitted within the first 28 days. No complications were related to the surgery being done as day case. Except one, all patients described the experience as excellent or good. Conclusion: Per case the cost savings are estimated to be £880 in comparison to 20 matched inpatient ankle replacements. We conclude that ankle replacements can be safely carried out as day case with appropriate patient selection, pre-operative education and a multi-disciplinary approach.

Effect of institution volume on mortality and outcomes in osteoporotic hip fracture care.

Hospitals that treat more patients with osteoporotic hip fractures do not generally have better care outcomes than those that treat fewer hip fracture patients. Institutions that do look after more such patients tend, however, to more consistently perform relevant health assessments. INTRODUCTION: An inveterate link has been found between institution case volume and a wide range of clinical outcomes; for a host of medical and surgical conditions. Hip fracture patients, notwithstanding the significance of this injury, have largely been overlooked with regard to this important evaluation. METHODS: We used the UK National Hip Fracture database to determine the effect of institution hip fracture case volume on hip fracture healthcare outcomes in 2019. Using logistic regression for each healthcare outcome, we compared the best performing 50 units with the poorest performing 50 institutions to determine if the unit volume was associated with performance in each particular outcome. RESULTS: There were 175 institutions with included 67,673 patients involved. The number of hip fractures between units ranged from 86 to 952. Larger units tendered to perform health assessments more consistently and mobilise patients more expeditiously post-operatively. However, patients treated at large institutions did not have any shorter lengths of stay. With regard to most other outcomes there was no association between the unit number of cases and performance; notably mortality, compliance with best practice tariff, time to surgery, the proportion of eligible patients undergoing total hip arthroplasty, length of stay delirium risk and pressure sore risk. CONCLUSIONS: There is no relationship between unit volume and the majority of health care outcomes. It would seem that larger institutions tend to perform better at parameters that are dependent upon personnel numbers. However, where the outcome is contingent, even partially, on physical infrastructure capacity, there was no difference between larger and smaller units.

Factors associated with delirium and cognitive decline following hip fracture surgery.

AIMS: Postoperative delirium (POD) and postoperative cognitive decline (POCD) are common surgical complications. In the UK, the Best Practice Tariff incentivizes the screening of delirium in patients with hip fracture. Further, a National Hip Fracture Database (NHFD) performance indicator is the reduction in the incidence of POD. To aid in its recognition, we sought to determine factors associated with POD and POCD in patients with hip fractures. METHODS: We interrogated the NHFD data on patients presenting with hip fractures to our institution from 2016 to 2018. POD was determined using the 4AT score, as recommended by the NHFD and UK Department of Health. POCD was defined as a decline in Abbreviated Mental Test Score (AMTS) of two or greater. Using logistic regression, we adjusted for covariates to identify factors associated with POD and POCD. RESULTS: Of the 1,224 patients presenting in the study period, 1,023 had complete datasets for final analysis. POD was observed in 242 patients (25%). On multivariate analysis only preoperative AMTS and American Society of Anesthesiologists grade (ASA) were independent predictors of POD. Every point increase in AMTS was associated with a fall in the odds of POD by a factor of 0.60 (95% confidence interval (CI) 0.56 to 0.63, p < 0.001). Every grade increase in ASA led to a 1.7-fold increase in the odds of POD (95% CI 1.13 to 2.50, p = 0.009). A preoperative AMTS of less than 8 was strongly predictive of POD with area under the receiver operating characteristic of 0.86 (95% CI 0.84 to 0.89). Only ASA was predictive of POCD-every grade increase in ASA led to a 2.6-fold increase in the odds of POCD (95% CI 1.7 to 4.0, p < 0.001). CONCLUSION: POD and POCD are common in the hip fracture patients. Preoperative AMTS and ASA are strong predictors of POD, and ASA predictive of POCD. This may aid in the earlier identification of those most at risk and suited for the patient consent and decision-making process. Cite this article: Bone Joint J 2020;102-B(12):1675-1681.

Heliovaccination: Solar mediated immunity against cancer.

The protective effect of ultraviolet (UV) light against a host of malignancies is well characterised. It was recognised by WHO in their 2006 publication on the global burden of UV-mediated disease. The mechanism by which this oncoprotective effect occurs remains unclear. Vitamin D has been mooted as a potential mediator. However, the evidence does not support this. I suggest that UV irradiation of the skin produces nascent malignant and premalignant cells with associated generic tumor-specific antigens. These are eliminated by immunosurveillance resulting in adaptive immunity. The clonal expansion of these immune cells protects against tumors in other viscera, effectively immunising the host. The evidence for this "heliovaccination" is very strong. Childhood UV exposure protects against cancer in adulthood. Tumor naïve individuals possess anti-tumor antibodies. Antigen-presenting cells mobilise to the skin following specifically UVB skin irradiation. It is time to rethink the link between UV light and cancer.

Management of achilles tendon injury: A current concepts systematic review.

Achilles tendon rupture has been on the rise over recent years due to a variety of reasons. It is a debilitating injury with a protracted and sometimes incomplete recovery. Management strategy is a controversial topic and evidence supporting a definite approach is limited. Opinion is divided between surgical repair and conservative immobilisation in conjunction with functional orthoses. A systematic search of the literature was performed. Pubmed, Medline and EmBase databases were searched for Achilles tendon and a variety of synonymous terms. A recent wealth of reporting suggests that conservative regimens with early weight bearing or mobilisation have equivalent or improved rates of re-rupture to operative regimes. The application of dynamic ultrasound assessment of tendon gap may prove crucial in minimising re-rupture and improving outcomes. Studies employing functional assessments have found equivalent function between operative and conservative treatments. However, no specific tests in peak power, push off strength or athletic performance have been reported and whether an advantage in operative treatment exists remains undetermined.

Hip fractures sustained in hospital: comorbidities and outcome.

BACKGROUND: Guidelines on the management of hip fracture in the elderly focus on fractures suffered in the community. Between 4% and 7% of hip fractures occur in hospital. Mortality is higher in those who sustain hip fracture in hospital than those who sustain a fracture in the community. However, it is not known if sustaining a nosocomial fracture is an independent risk factor for a poor outcome. OBJECTIVE: To compare outcomes of hip fracture sustained in the community and sustained while in hospital for another reason. After adjusting for confounders, we sought to determine if sustaining a fracture in hospital was an independent risk factor for a poor outcome. METHODS: Using the National Hip Fracture Database, we identified all patients admitted to Leicester Royal Infirmary with hip fracture between July 2009 and February 2013. We extracted demographic data, details of comorbidity, and 30-day and long-term mortality. Age, gender, American Society of Anaesthesiologists (ASA) grade, time to surgery, and survival were compared between patients with hospital-acquired and those with community-acquired hip fracture. RESULTS: During the study period, 2987 patients were treated for hip fracture; 2984 were included in the study. Of these, 261 (8.7%) sustained the fracture while in hospital. Those who sustained the fracture in hospital were more commonly men (106/261 (41%)) than those with a community-acquired fracture (738/2723 (27%)) and had a worse ASA grade (III or IV, 215/230 (93%) vs 1647/2573 (64%)). Thirty-day mortality was higher in those with a hospital-acquired fracture (48/261 (18%)) than in those with a community-acquired fracture (212/2723 (7.8%)) (p<0.001). However, after adjustment for confounding variables, the association between hip fracture, in-hospital and 30-day mortality was not significant: OR 1.2 (95% CI 0.8 to 2.0), p=0.40. Longer-term mortality was associated with hip fracture in hospital after adjustment for confounding variables in multivariate proportional hazards regression: HR 1.5 (95% CI 1.2 to 1.8), p<0.001. CONCLUSIONS: Patients who sustain hip fractures in hospital are unsurprisingly sicker than those who sustain hip fractures in the community. Although being in hospital is not an independent risk factor, this easily identifiable group of patients are at particular risk of a poor outcome. We suggest that it might be appropriate to consider modifying the guidelines for treatment of hip fracture for this group in an attempt to improve outcome.

Is body temperature an independent predictor of mortality in hip fracture patients?

INTRODUCTION: Admission body temperature is a critical parameter in all trauma patients. Low admission temperature is strongly associated with adverse outcomes. We have previously shown, in a prospective study that low admission body temperature is common and associated with high mortality in hip fracture patients (Uzoigwe et al., 2014). However, no previous studies have evaluated whether admission temperature is an independent predictor of mortality in hip fracture patients after adjustment for the 7 recognised independent prognostic indicators (Maxwell et al., 2008). METHODS: We retrospectively collated data on all patients presenting to our institution between June 2011 and February 2013 with a hip fracture. This included patients involved in the original prospective study (Uzoigwe et al., 2014). Admission tympanic temperature, measured on initial presentation at triage, was recorded. The prognosticators of age, gender, source of admission, abbreviated mental test score, haemoglobin, co-morbid disease and the presence or absence of malignancy were also recorded. Using multiple logistic regression, adjustment was made for these potentially confounding prognostic indicators of 30-day mortality, to determine if admission low body temperature were independently linked to mortality. RESULTS: 1066 patients were included. 781 patients, involved in the original prospective study (Uzoigwe et al., 2014), presented in the relevant time frame and were included in the retrospective study. The mean age was 81. There were 273 (26%) men and 793 (74%) women. 407 (38%) had low body temperature (<36.5 °C). Adjustment was made for age, gender, source of admission, abbreviated mental test score, haemoglobin, co-morbid disease and the presence or absence of malignancy. Those with low body temperature had an adjusted odds ratio of 30-day mortality that was 2.1 times that of the euthermic (36.5­37.5 °C). CONCLUSIONS: Low body temperature is strongly and independently associated with 30-day mortality in hip fracture patients.

Developmental dysplasia of the hip in the newborn: A systematic review.

Developmental dysplasia of the hip (DDH) denotes a wide spectrum of conditions ranging from subtle acetabular dysplasia to irreducible hip dislocations. Clinical diagnostic tests complement ultrasound imaging in allowing diagnosis, classification and monitoring of this condition. Classification systems relate to the alpha and beta angles in addition to the dynamic coverage index (DCI). Screening programmes for DDH show considerable geographic variation; certain risk factors have been identified which necessitate ultrasound assessment of the newborn. The treatment of DDH has undergone significant evolution, but the current gold standard is still the Pavlik harness. Duration of Pavlik harness treatment has been reported to range from 3 to 9.3 mo. The beta angle, DCI and the superior/lateral femoral head displacement can be assessed via ultrasound to estimate the likelihood of success. Success rates of between 7% and 99% have been reported when using the harness to treat DDH. Avascular necrosis remains the most devastating complication of harness usage with a reported rate of between 0% and 28%. Alternative non-surgical treatment methods used for DDH include devices proposed by LeDamany, Frejka, Lorenz and Ortolani. The Rosen splint and Wagner stocking have also been used for DDH treatment. Surgical treatment for DDH comprises open reduction alongside a combination of femoral or pelvic osteotomies. Femoral osteotomies are carried out in cases of excessive anteversion or valgus deformity of the femoral neck. The two principal pelvic osteotomies most commonly performed are the Salter osteotomy and Pemberton acetabuloplasty. Serious surgical complications include epiphyseal damage, sciatic nerve damage and femoral neck fracture.

Early and ultra-early surgery in hip fracture patients improves survival.

BACKGROUND: Hip fracture is a common injury with associated high mortality. Recent drives by the Department of Health have sought to prioritise these patients' care. In April 2010, the Best Practice Tariff was introduced in England and Wales. This offers financial incentives to institutions that provide holistic care and surgery within 36h for hip fracture patients. The England and Wales National Institute for Health and Clinical Excellence (NICE) published its first guidance on hip fracture management in June 2011, and emphasised the need for surgery on the day or day after admission. In spite of the emphasis placed on this injury, the predictors of in-hospital mortality remain ill-defined. In particular the effect of the timing of surgery remains contentious. OBJECTIVE: To address the issues raised by NICE around surgical timing and examine whether surgery before a 36h watershed improves survival. In addition, to examine survival outcomes for each 12h watershed following admission. MATERIALS AND METHODS: Prospectively collected data on 2056 patients presenting to our unit with hip fractures between February 2008 and May 2011 were retrospectively reviewed. Multivariate regression analysis was used to correct for confounders, and so determine the effect of various parameters on in-patient mortality. RESULTS: Age (p<0.0001), male-gender (p<0.0001), source of admission (p<0.05), ASA-grade (p<0.0001) and delay of surgery (p<0.01) were associated with an increased risk of in-hospital mortality. The adjusted odds of in-hospital mortality were 1.58 (p<0.05) times higher in those undergoing surgery after 36h compared to surgery before this time. Early surgery (within 24h) resulted in reduced in-hospital mortality when compared to the 36h watershed. Similarly ultra-early surgery (within 12h) was even better still (adjusted odds ratio 3.9 p<0.05). CONCLUSIONS: Expeditious surgery is associated with improved patient survival. Other predictors of in-hospital mortality include age, gender, in-hospital fracture and ASA-grade. Ultra-early surgery (within 12h) reduces risk of in-hospital mortality.

Primary and revision THA using a stemless metaphyseal-loading implant above distorted proximal femoral anatomy.

Total hip arthroplasty is well established as a successful treatment for end stage arthritis, with a wide variety of components currently available. Using traditional stemmed implants in patients with a distorted proximal femur can be technically challenging with an increased risk of complications. We present seven patients with distorted proximal femoral anatomy or failed hip arthroplasty in whom a short, metaphyseal loading implant was utilised. At minimum two-year follow-up there have been no complications with all stems stable and well fixed radiologically. Average improvement in Oxford Hip Score is 32. We suggest that a short, metaphyseal loading prosthesis can be considered in cases where a conventional stemmed implant may not be suitable due to challenging proximal femoral anatomy.

Serum lactate is a prognostic indicator in patients with hip fracture.

BACKGROUND AND PURPOSE: Serum lactate has been shown to be an indicator of adverse clinical outcomes in patients admitted secondary to general trauma or sepsis. We retrospectively investigated whether admission serum venous lactate can predict in-hospital mortality in patients with hip fractures. METHOD AND RESULTS: Over a 38-month period the admission venous lactate of 807 patients with hip fractures was collated. Mean age was 82 years. The overall in-hospital mortality for this cohort was 9.4%. Mortality was not influenced by the fracture pattern or the type of surgery - be it internal fixation or arthroplasty (p = 0.7). A critical threshold of 3 mmol/L with respect to the influence of venous lactate level on mortality was identified. Mortality rate in those with a lactate level of less than 3 mmol/L was 8.6% and 14.2% for those whose level was 3 mmol/L or greater. A 1 mmol/L increase in venous lactate was associated with a 1.2 (1.02-1.41) increased risk of in-hospital mortality. Patients with a venous lactate of 3 mmol/L or higher had twice the odds of death in hospital compared to matched individuals. There was no statistically significant difference in ASA distribution between those with a lactate of less than or greater than 3 mmol/L. CONCLUSIONS: Patients with an elevated venous lactate following hip trauma should be identified as being at increased risk of death and may benefit from targeted medical therapy.

Thromboprophylaxis in spinal surgery: a survey.

BACKGROUND: Venous Thromboembolism (VTE) is the most common complication following major joint surgery. While attention has been focused upon the incidence of thromboembolic disease following total hip or knee arthroplasty or emergency surgery for hip fracture, there exists a gap in the medical literature examining the incidence of VTE in spinal surgery. Evidence suggests that the prevalence of DVT after spinal surgery is higher than generally recognized but with a shortage of epidemiological data, guidelines for optimal prophylaxis are limited. This survey, of individuals attending the 2009 British Association of Spinal Surgeons Annual Meeting, sought to examine prevailing trends in VTE thromboprophylaxis in spinal surgery, adherence to guideline outlined by the National Institute for Health and Clinical Excellence (NICE) and to compare selections made by orthopaedic and neurosurgeons. METHODS: We developed a questionnaire with eight clinical scenarios. Participants were asked to supply details on their specialty and to select which method(s) of thromboprophylaxis they would employ for each scenario. Chi squared analysis was used for statistical comparison of the questionnaire responses. RESULTS: 73% of neurosurgical respondents' and 31% of orthopaedic surgeons employed low molecular weight heparin (p < 0.001). Neurosurgeons also selected anti-embolism stockings more frequently (79% v 50%) while orthopaedic surgeons preferred mechanical prophylaxis (26% v 9%). There was no significant difference between trauma and non-trauma scenarios (p = 0.05). CONCLUSION: There is no clear consensus in thromboprophylaxis in spinal surgery. There was a significant difference in selections across surgical disciplines with neurosurgeons more closely adhering to national guidelines. Further research examining the epidemiology of venous thromboembolism in spinal surgery and the risks-benefit relationship of thromboprophylaxis is warranted.

Representation to the accident and emergency department within 1-year of a fractured neck of femur.

BACKGROUND: The fractured neck of femur (NOF) is a leading cause of morbidity and mortality. The mortality attendant upon such fractures is 10% at 1 month and 30% at one year with a cost to the NHS of £1.4 billion annually. This retrospective study sought to examine rates and prevailing trends in representation to A&E in the year following a NOF fracture in an attempt to identify the leading causes behind the morbidity and mortality associated with this fracture. METHODS: 1108 patients who suffered a fractured NOF between 1 January 2002 and 31 December 2007 were identified from a University Hospital A&E database. This database was then used to identify those patients who represented within 1-year following the initial fracture. The presenting complaint, provisional diagnosis and the outcome of this presentation were identified at this time. RESULTS: 234 patients (21%) returned to A&E on 368 occasions in the year following a hip fracture. 77% (284/368) of these presentations necessitated admission. Falls, infection and fracture were the leading causes of representation. Falls accounted for 20% (57/284) of admissions; 20.7% of patients were admitted because of a fracture, while 56.6% of admissions were for medical ailments of which infection was the chief precipitant (28% (45/161)). DISCUSSION: The causes for representation are varied and multifactorial. The results of this study suggest that some of those events or ailments necessitating readmission may be obviated and potentially reduced by interventions that can be instituted during the primary admission and continued following discharge.