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.

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.

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.

Another look: is there a flaw to current hip septic arthritis diagnostic algorithms?

BACKGROUND: Septic arthritis is an emergency. In 1999 Kocher et al. identified four clinical criteria to distinguish hip septic arthritis from transient synovitis in children (nonweightbearing, erythrocyte sedimentation rate ≥ 40 mm/L, white blood cell count > 12 × 10(9)/L, temperature > 38.5°C). Subsequent authors evaluating the same criteria produced conflicting results. This calls into question the use of such diagnostic algorithms. The reasons for the differences remain unclear. QUESTIONS/PURPOSES: To what degree do studies, evaluating the predictive ability of diagnostic algorithms for septic arthritis, differ with regard to their results? Why do these differences exist? Is there a flaw in the statistical handling of the data? METHODS: Using PubMed, original studies evaluating the clinical criteria for distinguishing hip septic arthritis and transient synovitis in children were identified. Clinical and statistical methods were examined. RESULTS: Six studies evaluated the clinical criteria. Two found all four criteria able to distinguish septic arthritis from transient synovitis. There was significant variation between the studies in the risk engendered by the presence of each criteria. The differences were the result of the fact that in all cases, sample sizes were too small and in three cases, there were too few episodes of septic arthritis for a reliable predictive algorithm to be produced. CONCLUSIONS: Differing results between studies appear as a result of sample size and insufficient cases of septic arthritis in some cohorts. Transferable and reliable results can be achieved if sufficiently large samples with an adequate number of cases of septic arthritis are recruited.

Periprosthetic Femoral Fractures-Beyond B2.

The proliferation of hip arthroplasty has seen concomitant increases in periprosthetic femoral fractures (PFFs). The most common pattern involves fracture at the level of a loose prosthesis (B2). B2 PFFs have a unique mechanopathogenesis linked to the tendency of polished taper-slip cemented stems to subside in the cement. Such stems carry a much higher PFF risk than other cemented designs. Mega-data, consistent across national registries, suggest that increasing application of the taper-slip principle has resulted in the emergence of highly polished, very low friction cemented prostheses. These have the propensity to migrate within the cement, increasing B2 PFF risk. This would explain the strong association between cobalt-chromium stems and PFF. Is PFF the mode of failure of polished taper-slip stems rather than aseptic loosening? Established wisdom teaches that B2 PFFs should be managed with revision surgery. There is a large body of new evidence that, in certain instances, fixation results in outcomes at least equivalent to revision arthroplasty, with shorter surgical time, decreased transfusion requirements, and lower dislocation risk. This is so in B2 PFFs around cemented polished taper-slip stems with an intact bone-cement interface. We outline advances in understanding of B2 PFF with special reference to mechanopathogenesis and indications for fixation.

Patents and intellectual property in orthopaedics and arthroplasty.

The provision of musculoskeletal services comes at a cost. This is, in part, due to the expense of patent-protected orthopaedic implants. However, patents have a finite lifespan. Patents of the most successful implants are now beginning to expire. They will be exposed to competition from generic but equivalent implants. The net effect is potentially a dramatic diminution in cost. One company, Orthimo, has taken advantage of this and begun manufacturing generic implants with identical design specifications to the most bio-durable hip prostheses. This will ultimately have a radical impact upon musculoskeletal healthcare provision with regard to cost and accessibility. The expiration of drug patents, with the subsequent use of generic drugs saves £7.1 billion annually in the United Kingdom and $254 billion in the USA. Estimates suggest the introduction of equivalent implants could result in an annual cost saving to the United Kingdom National Health Service of £120 million. Intellectual property remains an enigmatic area of law. It encompasses anodyne principles that seek to protect innovation but are open to manipulation and exploitation. The last decade has seen the emergence of undesirable practices in the medical industry such as "patent trolling". Here we explore patents and their repercussions for musculoskeletal care.