The characteristics and predictors of mortality in periprosthetic fractures around the knee.

Aims: Periprosthetic fractures (PPFs) around the knee are challenging injuries. This study aims to describe the characteristics of knee PPFs and the impact of patient demographics, fracture types, and management modalities on in-hospital mortality. Methods: Using a multicentre study design, independent of registry data, we included adult patients sustaining a PPF around a knee arthroplasty between 1 January 2010 and 31 December 2019. Univariate, then multivariable, logistic regression analyses were performed to study the impact of patient, fracture, and treatment on mortality. Results: Out of a total of 1,667 patients in the PPF study database, 420 patients were included. The in-hospital mortality rate was 6.4%. Multivariable analyses suggested that American Society of Anesthesiologists (ASA) grade, history of peripheral vascular disease (PVD), history of rheumatic disease, fracture around a loose implant, and cerebrovascular accident (CVA) during hospital stay were each independently associated with mortality. Each point increase in ASA grade independently correlated with a four-fold greater mortality risk (odds ratio (OR) 4.1 (95% confidence interval (CI) 1.19 to 14.06); p = 0.026). Patients with PVD have a nine-fold increase in mortality risk (OR 9.1 (95% CI 1.25 to 66.47); p = 0.030) and patients with rheumatic disease have a 6.8-fold increase in mortality risk (OR 6.8 (95% CI 1.32 to 34.68); p = 0.022). Patients with a fracture around a loose implant (Unified Classification System (UCS) B2) have a 20-fold increase in mortality, compared to UCS A1 (OR 20.9 (95% CI 1.61 to 271.38); p = 0.020). Mode of management was not a significant predictor of mortality. Patients managed with revision arthroplasty had a significantly longer length of stay (median 16 days; p = 0.029) and higher rates of return to theatre, compared to patients treated nonoperatively or with fixation. Conclusion: The mortality rate in PPFs around the knee is similar to that for native distal femur and neck of femur fragility fractures. Patients with certain modifiable risk factors should be optimized. A national PPF database and standardized management guidelines are currently required to understand these complex injuries and to improve patient outcomes.

No clinical advantage with customized individually made implants over conventional off-the-shelf implants in total knee arthroplasty: a systematic review and meta-analysis.

INTRODUCTION: Total knee arthroplasty (TKA) can be performed with either conventional off-the-shelf (OTS) or customized individually-made (CIM) implants. The evidence for CIM implants is limited and variable, and the aim of this review was to compare clinical and radiological outcomes between CIM and OTS implants. METHODS: A systematic review and meta-analysis were conducted in accordance with PRISMA guidelines. Studies reporting on clinical, radiological, or alignment outcomes for CIM and OTS implants were selected. The studies were appraised using the Methodical index for non-randomized studies tool. RESULTS: Twenty-three studies fulfilled the inclusion criteria. The studies comprised 2856 CIM and 1877 OTS TKAs. Revision rate was higher with CIM (5.9%) compared to OTS (3.7%) implants [OR 1.23(95% CI 0.69-2.18)]. Manipulation under anesthesia (MUA) was higher in CIM (2.2%) compared to OTS (1.1%) group [OR 2.95(95% CI 0.95-9.13)] and complications rate was higher in CIM (5%) vs. OTS (4.5%) [OR 1.45(95% CI 0.53-3.96)] but neither reached statistical significance. Length of stay was significantly shorter in CIM group 2.9 days vs. 3.5 days [MD - 0.51(95% CI - 0.82 to - 0.20)]. Knee Society Score showed no difference between CIM and OTS groups for Knee 90.5 vs. 90.6 [MD - 0.27(95% CI - 4.27 to 3.73)] and Function 86.1 vs. 83.1 [MD 1.51(95% CI - 3.69 to 6.70)]. CONCLUSION: CIM implants in TKA have theoretical benefits over OTS prostheses. However, in this present review, CIM implants were associated with higher revisions, MUA, and overall complication rates. There was no difference in outcome score and CIM implants did not improve overall target alignment; however, more CIM TKAs were found to be in the HKA target zone compared to OTS TKAs. The findings of this review do not support the general utilization of CIM over OTS implants in TKA.

Predictors of mortality in periprosthetic fractures of the hip: Results from the national PPF study.

INTRODUCTION: Periprosthetic fractures (PPFs) around the hip joint are increasing in prevalence. In this collaborative study, we aimed to investigate the impact of patient demographics, fracture characteristics, and modes of management on in-hospital mortality of PPFs involving the hip. METHODS: Using a multi-centre cohort study design, we retrospectively identified adults presenting with a PPF around the hip over a 10-year period. Univariate and multivariable logistic regression analyses were performed to study the independent correlation between patient, fracture, and treatment factors on mortality. RESULTS: A total of 1,109 patients were included. The in-hospital mortality rate was 5.3%. Multivariable analyses suggested that age, male sex, abbreviated mental test score (AMTS), pneumonia, renal failure, history of peripheral vascular disease (PVD) and deep surgical site infection were each independently associated with mortality. Each yearly increase in age independently correlates with a 7% increase in mortality (OR 1.07, p=0.019). The odds of mortality was 2.99 times higher for patients diagnosed with pneumonia during their hospital stay [OR 2.99 (95% CI 1.07-8.37) p=0.037], and 7.25 times higher for patients that developed renal failure during their stay [OR 7.25 (95% CI 1.85-28.47) p=0.005]. Patients with history of PVD have a six-fold greater mortality risk (OR 6.06, p=0.003). Mode of treatment was not a significant predictor of mortality. CONCLUSION: The in-hospital mortality rate of PPFs around the hip exceeds 5%. The fracture subtype and mode of management are not independent predictors of mortality, while patient factors such as age, AMTS, history of PVD, pneumonia, and renal failure can independently predict mortality. Peri-operative optimisation of modifiable risk factors such as lung and kidney function in patients with PPFs around the hip during their hospital stay is of utmost importance.

The rise in trauma & orthopaedic trainee-led research and audit collaborative projects in the United Kingdom since the start of the COVID-19 pandemic.

Background and Objective: A significant increase has been observed globally in multi-centre trainee-led trauma & orthopaedic (T&O) research collaborative projects with more emphasis have been on tackling important research questions since the start of the COCID-19 pandemic. The objective of our analysis was to determine the number of trainee-led research collaborative projects in T&O in the United Kingdom that were started during the COVID-19 pandemic. Methods: A retrospective analysis was conducted to determine how many trainee-led national collaborative projects in T&O were conducted since the start of the COVID-19 pandemic lockdown (March 2020 to June 2021) and the number of projects identified were compared to the previous year (2019). Any regional collaborative projects, projects that were started before the onset of COVID and projects of other surgical specialities were not included in the study. Results: There were no projects identified in 2019 while in the Covid pandemic lockdown we identified 10 trainee-led collaborative trauma & orthopaedic projects with six of them being published with level of evidence from three to four. Conclusion: Covid was unprecedented and has placed considerable trials across healthcare. Our study highlights an increase in multi-centre trainee-led collaborative projects within the UK and it underlines the feasibility of such projects especially with the advent of social media and Redcap® which facilitate recruitment of new studies and data.

Establishment Of Virtual Fracture Clinic In Princess Royal Hospital Telford: Experience And Recommendations During The First 9 Months.

BACKGROUND: Virtual fracture clinics (VFC) have been shown to be a safe and cost-effective way of managing outpatient referrals to the orthopaedic department. During the coronavirus pandemic there has been a push to reduce unnecessary patient contact whilst maintaining patient safety. METHODS: A protocol was developed by the clinical team in collaboration with Advanced Physiotherapy Practitioners (APP) on how to manage common musculoskeletal presentations to A&E prior to COVID as part of routine service development. Patients broadly triaged into 4 categories; discharge with advice, referral to VFC, referral to face to face clinic or discussion with on call team. The first 9 months of data were analysed to assess types of injury seen and outcomes. RESULTS: In total 2489 patients were referred to VFC from internal and external sources. Seven hundred and thirty-four patients were discharged without follow-up and 182 patients were discharged for physiotherapy review. Only 3 patients required admission. Regarding follow-ups, 431 patients had a virtual follow-up while 1036 of patients required further face to face follow up. Eighty-seven patients were triaged into subspecialty clinics. Thirty-seven patients were felt to have been referred inappropriately. Discussion: British Orthopaedic Association guidelines suggest all patients need to be reviewed within 72 hours of their orthopaedic injury. Implementation of a VFC allows this target to be achieved and at the same time reduce patient contact. Almost half the patients were discharged following VFC review; the remaining patients were appropriately followed up. This is especially relevant in the current pandemic where reducing unnecessary trips to hospital will benefit the patient as well as make the most of the resources available.

Addressing the failures of undergraduate anatomy education: Dissecting the issue and innovating a solution.

BACKGROUND: Reduced time allocation, changes in teaching methods and Covid-19 have resulted in undergraduate anatomy teaching being marginalised.This has implications on patient safety, litigation, student satisfaction and surgical workforce planning. AIMS: The aim of this study is to survey a cohort of recent English medical graduates to attain their perspective on anatomy training and to propose an innovative solution to solve existing problems in undergraduate anatomy training. METHODS: An online survey was sent out to 40 foundation doctors to offer insights into their undergraduate anatomy training. We asked participants to rate their perceived importance of anatomy, the importance offered to anatomy teaching at undergraduate level, preparation for clinical practice and future career plans. RESULTS: 22 participants responded to the online survey. All trained across England with equal spread between Northern and Southern medical schools. All participants perceived anatomy to be either important or very important in the survey. 20/22 felt that their undergraduate anatomy teaching was given very low to average importance by their institutions. 8/22 were confident or very confident with their anatomy knowledge on beginning clinical practice. Of the 22, 5 planned surgical careers, 10 did not know or gave other responses and 7 wanted to do General Practice. 16/22 said anatomy training had or will impact their decision on choosing a speciality. CONCLUSION: The current literature and above survey highlight the deficiencies that current doctors are facing.We suggest implementation of a standardised anatomy curriculum and the development of an online anatomy course.

Fixed-Life or Rechargeable Battery for Deep Brain Stimulation: A Prospective Long-Term Study of Patient's Preferences.

INTRODUCTION: Deep brain stimulation (DBS) is an established treatment for movement disorders. We have previously shown that in our practice, the majority of adult patients prefer fixed-life implantable pulse generators (IPGs), although rechargeable batteries are increasingly used. The aim of this study was to evaluate patients' long-term satisfaction with their choice of battery and factors that influence their decision. METHODS: Thirty patients with DBS were given a questionnaire to assess long-term satisfaction and experience with the type of battery they had chosen. RESULTS: Twenty-six patients completed the survey. The mean age was 67.7 ± 7.3 years, and mean follow-up was 18.0 ± 7.2 months. The indications for DBS were Parkinson's disease (76.9%), tremor (11.5%) and dystonia (11.5%). Eleven patients (42.5%) had chosen the rechargeable battery. All patients were still happy with their choices and would not change the type of battery if they had the chance to do so. However, in patients who chose the fixed-life battery, concern about the size of battery rose from 6.7% pre-operatively to 60% on long-term post-operative follow-up. In patients who chose the rechargeable battery, concern about the need to recharge the battery did not change, remaining low postoperatively. Interestingly, even though the main reason cited for choosing the fixed-life battery was the convenience and concern about forgetting to recharge the battery, patients who had chosen a rechargeable IPG did not experience this problem. CONCLUSION: Patients and caregivers should be involved in the choice of battery, as each type of IPG has its own advantages and disadvantages. Long-term evaluation of patient's experience and satisfaction with battery of choice revealed that size of the IPG, need for further replacement surgeries and need for recharging remain matters of major concern. Although preoperatively often underestimated, the size of the battery seems to be an important factor in long-term satisfaction.

Fixed-Life or Rechargeable Battery for Deep Brain Stimulation: Which Do Patients Prefer?

BACKGROUND: Deep brain stimulation (DBS) is increasingly used to treat a wide variety of neurological and psychiatric disorders. Implantable pulse generators (implantable pulse generators/batteries) for DBS were originally only available as a nonrechargeable option. However, there is now a choice between fixed-life and rechargeable batteries, with each having their own advantages and disadvantages. The extent of patient involvement in the choice of battery and the factors that matter to them have not been well studied. METHODS: Thirty consecutive adult patients with movement disorders attending a pre-DBS clinic were offered a choice of fixed-life or rechargeable battery and completed a questionnaire after the consultation on which factors influenced their decision. RESULTS: Nineteen patients (63%) chose the fixed-life battery and 11 patients (37%) chose the rechargeable battery. There were no significant differences in age, sex, underlying disease, disease duration or Unified Parkinson's Disease Rating Scale (UPDRS) (part 3) score (for patients with Parkinson disease) between those who chose the fixed-life vs. rechargeable battery. Most patients were not concerned about the size of the battery. Equal numbers were concerned about surgery to replace the battery, and less than half were concerned about the need to recharge the battery. More than half of patients felt that an acceptable charging frequency was monthly or yearly, and all patients felt that an acceptable charging duration was less than 1 hour, with half of all patients choosing less than 30 min. The main reasons cited for choosing the fixed-life battery were convenience and concern about forgetting to recharge the battery. The main reason for choosing the rechargeable battery was the avoidance of further surgery. DISCUSSION: Most patients in this adult cohort with movement disorders chose the fixed-life battery. The better lifestyle associated with a fixed-life battery is a major factor influencing their choice. Rechargeable batteries may be more acceptable if the recharging process is improved, more convenient, and discreet. CONFLICT OF INTEREST: The authors' institution has received educational grants from Medtronic, Abbott, and Boston Scientific companies.

Sweat Gland Carcinoma With Lymphadenopathy.

Sweat gland carcinoma is a rare tumour, being almost 1% of primary skin lesions. The tumour has tendency to spread to regional lymph nodes and distant metastases has also been reported. Their exact incidence in Pakistan is not known. Treatment options are also not clearly defined though surgery is the initial treatment approach as adjuvant treatment has not been properly explored. We report a case of sweat gland carcinoma with lymphadenopathy.