National Institute of Health and Care Excellence Guidelines for Displaced Intracapsular Hip Fractures: Examining Satisfaction With the Guidelines and Effects on Outcomes.

BACKGROUND: The objectives of the study were to: (1) evaluate satisfaction with the new 2023 National Institute of Health and Care Excellence (NICE) criteria for selecting total hip arthroplasty (THA) over hemiarthroplasty and surgical recommendations for treatment of displaced intracapsular hip fractures; (2) describe why THA is performed when NICE criteria are not met; and (3) determine whether satisfaction with these guidelines is associated with improved outcomes. METHODS: A retrospective chart review of patients who had a displaced intracapsular hip fracture treated with THA at a single tertiary academic center between 2010 and 2022 was performed. Preoperative patient characteristics were reviewed to determine if the indication for THA met NICE criteria. Operative details, perioperative complications, reoperation, and revision arthroplasty within 12 months of surgery were recorded. RESULTS: Data from 196 patients (63% women; age 67 ± 10 years) were used. There were 161 THAs (82.1%) that satisfied NICE criteria. The 2 most common reasons for performing a THA when NICE criteria were not met (n = 35) included preoperative radiographic osteoarthritis (Tönnis grade ≥ 2; 48.6%) and decreased patient age (< 65 years; 31.5%). Satisfaction with the NICE criteria was associated with fewer perioperative complications (0.6 versus 37.1%; P < .001), reoperations (0.6 versus 31.4%; P < .001), and revisions (0.6 versus 28.6%; P < .001). The most common reason for revision was periprosthetic fracture, possibly secondary to the use of uncemented femoral stems (171 of 196, 87.2%). CONCLUSIONS: Satisfaction with the new NICE criteria is associated with improved perioperative outcomes. Further studies are necessary to determine if preexisting hip osteoarthritis and younger age merit consideration in patient selection.

Lower Rates of Reoperation Following Partial or Complete Revision Arthroplasty Compared to Debridement, Antibiotics, and Implant Retention for Early Postoperative and Acute Hematogenous Periprosthetic Hip Infection.

BACKGROUND: This study aimed to: 1) compare treatment outcomes between debridement, antibiotics, and implant retention (DAIR) and partial or complete revision arthroplasty (RA) for early postoperative and acute hematogenous total hip arthroplasty periprosthetic joint infection (PJI) and 2) identify factors associated with treatment outcome. METHODS: The study consisted of a retrospective cohort of patients who underwent surgery for PJI between 2004 and 2021. There were 76 patients (74.5%) who underwent DAIR and 26 patients (25.5%) who underwent RA. Treatment success was defined as treatment eradication at a minimum of a 2-year follow up. Bivariate regression analysis was used to assess the effect of different factors on treatment outcomes. Kaplan-Meier survivorship was performed to compare survivorship between cohorts. RESULTS: At a mean follow-up of 8.2 years (range, 2.2 to 16.4), significantly more DAIR failed treatment (DAIR, 50 [65.8%]; 10 [38.5%]; P = .015). The 8-year Kaplan-Meier survivorship was 35.1% [95% confidence interval (CI), 24.3 to 45.9] for patients treated with DAIR and 61.5% [95% CI, 42.9 to 80.1] for those treated with RA (log rank = 0.039). Bivariate regression analysis showed performing a RA was associated with a higher likelihood of treatment success (odds ratio 4.499, 95% CI 1.600 to 12.647, P = .004), whereas a higher body mass index was associated with treatment failure (odds ratio 0.934, 95% CI 0.878 to 0.994, P = .032). CONCLUSIONS: To reduce the rate of recalcitrant infection following early postoperative or acute hematogenous total hip arthroplasty PJI, RA may be of benefit over DAIR. This is especially relevant in the early postoperative period, when components can be readily exchanged.

Tibiotalar nailing using an antegrade intramedullary tibial nail: a salvage procedure for unstable distal tibia and ankle fractures in the frail elderly patient.

AIM: This article describes the technique of tibiotalar nailing performed using an antegrade tibial nail for salvage of distal tibia and ankle fractures in elderly patients. MATERIALS AND METHODS: We report indications, surgical technique, and the clinical outcomes and complication rate in our series to date. A retrospective review was performed at our level 1 major trauma centre. Patient demographics, comorbidities, and 12-month post-operative course were collected. Fractures were classified using the OTA/AO and modified Gustilo-Anderson classification. Fifteen patients underwent the procedure. We present data with a minimum 12-month follow-up. The median age of the patients in this cohort was 83 years (range, 51-102). Five patients were diabetic. Six patients (6/15; 40%) presented with an open fracture. RESULTS: At final follow-up, fourteen patients reported painless walking and had returned to baseline activity. CONCLUSION: This technique may serve as a salvage procedure, with indications similar to those for tibio-talar-calcaneal arthrodesis. Indications would include non-constructible pilon fractures, comminuted intra-articular fractures in low-demand patients, or patients at high risk of wound complications. LEVEL OF CLINICAL EVIDENCE: 3.

Management of complex regional pain syndrome in trauma and orthopaedic surgery-a systematic review.

INTRODUCTION: Complex regional pain syndrome (CRPS) is a neurological pain disorder that is challenging to diagnose and manage, resulting in increased morbidity and costs. It most commonly occurs following traumatic injury, such as a fracture, crush injury or surgery. Recent research has evaluated the efficacy of treatments which have contradicted previous hypotheses. This systematic review summarizes these findings to improve clinician's decision-making. SOURCES OF DATA: A comprehensive search of PubMed, MEDLINE and Embase databases from inception through January 2021 was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Two reviewers independently screened relevant articles discussing the management of CRPS in adult trauma patients. All prospective and retrospective studies, non-randomized comparison studies and case series were considered for inclusion. Data extraction was performed by populating a predefined data abstraction sheet. AREAS OF AGREEMENT: There is strong evidence to suggest the efficacy of prompt physiotherapy, lidocaine, ketamine, bisphosphonates, sympathectomy and brachial plexus blocks in the management of CRPS. AREAS OF CONTROVERSY: The latest evidence suggests that vitamin C has no significant role to play in the treatment or prevention of CRPS. GROWING POINTS: A multidisciplinary team approach and early diagnosis are imperative for successful treatment of CRPS. The Budapest criteria and the British Orthopaedic Association Standards for Trauma and Orthopaedics (BOAST) guidelines should be used when diagnosing CRPS. There is currently no clear evidence of superiority in any treatment. AREAS TIMELY FOR DEVELOPING RESEARCH: There are few high-quality studies that inform the best treatment modalities for CRPS. Though emerging treatments show promise, further research is needed.

Is Outcome of Total Hip Arthroplasty for Hip Fracture Inferior to That of Arthritis in a Contemporary Arthroplasty Practice?

BACKGROUND: Outcome of total hip arthroplasty (THA) for femoral neck fractures (FNF) has been associated with higher complication rates. However, THA for FNF is not always performed by arthroplasty surgeons. This study aimed to compare THA outcomes for FNF to osteoarthritis (OA). In doing so, we described contemporary THA failure modes for FNF performed by arthroplasty surgeons. METHODS: This was a retrospective, multisurgeon study from an academic center. Of FNFs treated between 2010 and 2020, 177 received THA by an arthroplasty surgeon [mean age 67 years (range, 42 to 97), sex: 64.4% women]. These were matched (1:2) for age and sex with 354 THAs performed for hip OA, by the same surgeons. No dual-mobilities were used. Outcomes included radiologic measurements (inclination/anteversion and leg length), mortality, complications, reoperation rates and patient-reported outcomes including Oxford Hip Score. RESULTS: Postoperative mean leg-length difference was 0 mm (range, -10 to -10 mm), with a mean cup inclination and anteversion of 41 and 26°, respectively. There was no difference in radiological measurements between FNF and OA patients (P = .3). At a 5-year follow-up, mortality rate was significantly higher in the FNF-THA group compared to the OA-THA group (15.3 versus 1.1%; P < .001). There was no difference in complications (7.3 versus 4.2%; P = .098) or reoperation rates (5.1 versus 2.9%; P = .142) between the groups. Dislocation rate was 1.7%. Oxford Hip Score at the final follow-up was similar [43.7 points (range, 10 to 48) versus 43.6 points (range, 10 to 48); P = .030]. CONCLUSION: THA for the treatment of FNF is a reliable option and is associated with satisfactory outcomes. Instability was not a common reason of failure, despite not using dual-mobility articulations in this at-risk population. This is likely due to THAs being performed by the arthroplasty staff. When patients live beyond 2 years, similar clinical and radiographic outcomes with low rates of revision can be expected compared to elective THA for OA. LEVEL OF EVIDENCE: III, case-control study.

Delayed mobilization following admission for hip fracture is associated with increased morbidity and length of hospital stay.

BACKGROUND: Current national guidelines on caring for hip fractures recommend early mobilization. However, this recommendation does not account for time spent immobilized waiting for surgery. We sought to determine timing of mobilization following hip fracture, beginning at hospital admission, and evaluate its association with medical complications and length of hospital stay (LOS). METHODS: We performed a retrospective review of prospectively collected data for 470 consecutive patients who underwent surgery for a hip fracture between September 2019 and August 2020 at an academic, tertiary-referral hospital. Outcomes of interest included time from hospital admission to mobilization, complication rate and LOS. We used a binary regression analysis to determine the effect of different surgical and patient factors on the risk of a postoperative medical complication. RESULTS: The mean time from admission to mobilization was 2.8 ± 2.3 days (range 3 h-14 d). There were 125 (26.6%) patients who experienced at least 1 complication. The odds of developing a complication began to increase steadily once a patient waited more than 3 days from admission to mobilization (odds ratio 2.15, 95% confidence interval 1.42-3.25). Multivariate regression analysis showed that prefracture frailty (ß = 0.276, p = 0.05), and timing from hospital admission to mobilization (ß = 0.156, p < 0.001) and from surgery to mobilization (ß = 1.195, p < 0.001) were associated with complications. The mean LOS was 12.2 ± 10.7 days (range 1-90 d). Prolonged wait to mobilization was associated with longer LOS (p = 0.01). CONCLUSION: Comprehensive guidelines on timing of mobilization following hip fracture should account for cumulative time spent immobilized.

Effects of Perioperative Selective Serotonin Reuptake Inhibitor Use in Primary Total Hip and Knee Arthroplasty.

BACKGROUND: The aim of this study is to compare functional outcomes and perioperative complications between patients on a selective serotonin reuptake inhibitor (SSRI) and those who are not on an SSRI preoperatively at the time of total joint arthroplasty. METHODS: A retrospective study was performed on 28,386 patients who received a primary total hip (THA) or knee (TKA) arthroplasty. Patients were compared based on SSRI utilization. We measured patient-reported function and health-related quality of life using the Western Ontario and McMaster Universities Arthritis Index (WOMAC) and the EuroQol-5 Dimensions (EQ-5D-5L) instruments. Chi-squared test was used to compare categorical variables and t-test was used to compare the continuous variables of 2 study groups. RESULTS: Patients on SSRIs have lower preoperative baseline WOMAC and EQ-5D-5L scores than those not using SSRI (P < .001). Patient-reported outcomes improved significantly following surgery, but functional outcome scores remained inferior in patients using SSRI. After adjusting for baseline variables, SSRI use in TKA predicted lower EQ-5D-5L scores than non-SSRI users (P = .036) while the WOMAC scores were not different (P = .118). For the THA cohort, SSRI use predicted lower EQ-5D-5L (P = .001) and WOMAC scores than non-SSRI users (P = .008). SSRI use was associated with increased transfusion rate, length of stay, readmission rate, and medical events. About 11.3% of TKA and 13.3% of THA patients stopped using SSRI at 12 months after arthroplasty. CONCLUSION: Patients using an SSRI show improvement comparable to patients not on an SSRI, but their 12-month functional scores continue to be inferior. SSRI utilization was associated with increased adverse events including needing a blood transfusion.

Comparing 1-year and 10-year whole blood metal ion results following Birmingham hip resurfacing for osteoarthritis.

BACKGROUND: Patients with metal-on-metal hip arthroplasty may develop adverse reactions to metal debris that can lead to clinically concerning symptoms, often needing revision surgery. As such, many regulatory authorities advocate for routine blood metal ion measurement. This study compares whole blood metal ion levels obtained 1 year following Birmingham Hip Resurfacing (BHR) to levels obtained at a minimum 10-year follow-up. METHODS: A retrospective chart review was conducted to identify all patients who underwent a BHR for osteoarthritis with a minimum 10-year follow-up. Whole blood metal ion levels were obtained at final follow-up in June 2019. These results were compared with patients' metal ion levels at 1 year. RESULTS: Of the 211 patients who received a BHR, 71 patients (54 males and 17 females) had long-term metal ion levels assessed (mean follow-up 12.7 ± 1.4 yr). The mean cobalt and chromium levels for patients with unilateral BHRs (43 males and 13 females) were 3.12 ± 6.31 µg/L and 2.62 ± 2.69 µg/L, respectively; for patients with bilateral BHRs (11 males and 4 females) cobalt and chromium levels were 2.78 ± 1.02 µg/L and 1.83 ± 0.65 µg/L, respectively. Thirty-five patients (27 male and 8 female) had metal ion levels tested at 1 year postoperatively. The mean changes in cobalt and chromium levels were 2.29 µg/L (p = 0.0919) and 0.57 µg/L (p = 0.1612), respectively. CONCLUSION: Our results suggest that regular metal ion testing as per current regulatory agency guidelines may be impractical for asymptomatic patients. Metal ion levels may in fact have little utility in determining the risk of failure and should be paired with radiographic and clinical findings to determine the need for revision.

Perioperative outcomes associated with general and spinal anesthesia after total joint arthroplasty for osteoarthritis: a large, Canadian, retrospective cohort study.

BACKGROUND: Compared with general anesthesia, spinal anesthesia has many benefits for patients undergoing total hip (THA) or total knee (TKA) arthroplasty, but few studies have explored rates of morbidity and mortality. We aimed to compare perioperative outcomes by anesthetic type for patients undergoing THA or TKA for osteoarthritis. METHODS: We identified patients who underwent primary THA or TKA from the affiliated institute's database. We calculated inpatient, 30-day, 60-day and 90-day mortality rates, as well as 90-day perioperative complications, readmissions and length of stay (LOS). We compared outcomes between groups using logistic regression and propensity-adjusted multivariate analysis. RESULTS: We included 6100 (52.2%) patients undergoing THA and 5580 (47.8%) undergoing TKA. We found no differences by anesthetic type in mortality rates up to 90 days after surgery. Patients under spinal anesthesia were less likely to need a blood transfusion (THA odds ratio [OR] 0.75, 95% confidence interval [CI] 0.60 to 0.92; TKA OR 0.52, 95% CI 0.40 to 0.67) and were more likely to be discharged home among those who underwent TKA (OR 1.61, 95% CI 1.30 to 2.00). Patients who received spinal anesthesia for THA had a longer LOS (0.28 d, 95% CI 0.17 to 0.39), and patients who received spinal anesthesia for TKA had a shorter LOS than those who received general anesthesia (-0.34 d, 95% CI -0.51 to -0.18). Anesthetic type was not associated with any difference in adverse events. CONCLUSION: These findings may inform decisions on anesthetic type for total joint arthroplasty, especially for rapid discharge protocols. Further research is needed to understand postoperative pain and functional outcomes between anesthetic types.

Birmingham Hip Resurfacing for osteoarthritis - a Canadian retrospective cohort study with a minimum 10-year follow-up.

BACKGROUND: Young men with osteoarthritis of the hip are a growing segment of the population requiring arthroplasty, and there is compelling evidence that the Birmingham Hip Resurfacing (BHR) system provides good functional outcomes and durability in young, active men. We reviewed the survivorship and clinical outcomes of patients who underwent BHR with a minimum follow-up of 10 years. METHODS: We analyzed survivorship using the Kaplan-Meier method. Functional scoring was performed using the Harris Hip Score (HHS), the University of California, Los Angeles (UCLA) Activity Score, and a visual analogue scale (VAS). RESULTS: In total, 211 patients (243 hips) were included in the study. Of these, 107 patients (127 hips) were available for long-term clinical follow-up, with a mean duration of 12.4 ± 1.4 years. The proportion of male participants with BHRs surviving past 13 years was 93.8% (95% confidence interval [CI] 87.9%-100%) compared with 87% (95% CI 77.8%-97.3%) of female patients. Eleven patients (11 hips) underwent BHR revision. Upon final follow-up, the median HHS was 93.9 in males and 93.6 in females (p = 0.27); median UCLA Activity Score was 8.2 in males and 7.2 in females (p < 0.001), and the median VAS score was 81.9 in males and 81.3 in females (p = 0.35). The median acetabular component inclination was 45.5° ± 6.0° (range 34.6°-57.2°) in males and 44.6° ± 5.9° (range 29°-58.9°) in females. The most common femoral head size was 50 mm with a 56 mm or 58 mm cup (36.3%). CONCLUSION: This study confirms that BHR provides good to excellent functional outcomes, lasting functional improvements, and acceptable durability beyond 10 years in men. Survivorship following BHR is inferior in women; however, HHS and VAS scores were similar in women and men.

Postoperative fever in the time of COVID-19.

Summary: Postoperative fever is common following orthopedic trauma surgery. As the prevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection increases in the community, migration into the acute care hospital setting intensifies, creating confusion when fever develops postoperatively. The transmission dynamics of SARS-CoV-2 make it difficult to adequately gauge and pinpoint risk groups with questionnaires at the time of hospital admission. This is particularly problematic when asymptomatic or presymptomatic patients infected with SARS-CoV-2 require urgent surgery and cannot be screened effectively. One approach is to treat every patient as though they were SARS-CoV-2-positive in preparation for surgery, but doing so could exacerbate shortages of personal protective equipment and staffing limitations. Uncertainty regarding the etiology of postoperative fever could be significantly reduced by universal SARS-CoV-2 testing of all surgical patients at the time of hospital admission in addition to routine screening, but testing capacity and a rapid turnaround time would be required.

A national survey of psychiatrists' attitudes towards the physical examination.

Background: Studies have shown that most psychiatric patients do not receive a thorough physical examination (PE).Aim: To explore factors contributing to the underperformance of the PE on psychiatric patients.Method: All psychiatrists in the UK who were registered or affiliated to the Royal College of Psychiatrists were invited to complete an online survey regarding their attitudes towards PEs in psychiatry.Results: Responses from 15% of the psychiatrists showed that most (89%) believe that the PE is important. The majority (61%) indicated that their PE skills had diminished since working in psychiatry and this was reported more by senior psychiatrists than junior trainees (64% vs. 49%). Most respondents considered that the PE should not be done by another type of health professional (45% vs. 28%).Conclusions: Likely reasons for poor performance of PEs include shortage of time and equipment, challenges associated with agitated and uncooperative patients, the perceived incongruence of the PE with the patient's presenting symptoms and a degree of skill atrophy, especially in senior psychiatrists which is leading to lack of supervision of junior trainees in this area. Further research is needed to investigate if strategies addressing these factors would improve the standard of PEs on psychiatric patients.

Understanding the role of total knee arthroplasty for primary treatment of tibial plateau fracture: a systematic review of the literature.

BACKGROUND: Surgical fixation of tibial plateau fracture in elderly patients with open reduction and internal fixation (ORIF) provides inferior outcomes compared with younger patients. Primary total knee arthroplasty (TKA) may be of benefit in elderly patients with a combination of osteoporotic bone and metaphyseal comminution. However, there continues to be conflicting evidence on the use of TKA for primary treatment of tibial plateau fracture. This systematic review was performed to quantify the outcomes and perioperative complication rates of TKA for primary treatment of tibial plateau fracture. MATERIALS AND METHODS: A comprehensive search of MEDLINE, Embase, and PubMed databases from inception through March 2018 was performed in accordance with PRISMA guidelines. Two reviewers independently screened papers for inclusion and identified studies featuring perioperative complications and outcomes of primary TKA for tibial plateau fracture. Weighted means and standard deviations are presented for each outcome. RESULTS: Seven articles (105 patients) were eligible for inclusion. All-cause mortality was 4.75 ± 4.85%. The total complication rate was 15.2 ± 17.3%. Regarding outcomes, Knee Society scores were most commonly reported. The average Knee Society Knee Score was 85.6 ± 5.5, while the average Knee Society Function Score was 64.6 ± 13.7. Average range of motion at final follow-up was 107.5 ± 10.0°. CONCLUSIONS: Primary TKA for select tibial plateau fractures has acceptable clinical outcomes but does not appear to be superior to ORIF. It may be appropriate to treat certain geriatric patients with TKA to allow for early mobilization and reduce the need for reoperation. Other factors may need to be considered in deciding the optimal treatment. LEVEL OF EVIDENCE: Level III.

Reinventing the wheel in scoliosis surgery: effective strategies for safely improving efficiency

Posterior spinal instrumentation and fusion (PSIF) has been the standard operative treatment for adolescent idiopathic scoliosis (AIS) and is one of the most frequently performed elective pediatric surgeries in North America, incurring an expenditure of more than $1.1 billion annually in the United States alone. This commentary reflects on the outcomes of systematically implementing intraoperative skull femoral traction (IOSFT) combined with navigated sequential drilling (NSD) during PSIF for AIS as strategies for quality improvement at our tertiary children's hospital.

A survey of psychiatrists' attitudes towards the physical examination.

BACKGROUND: Studies have shown that most psychiatric patients do not receive a thorough physical examination (PE). METHODS: Psychiatrists working with Leicestershire Partnership NHS Trust were surveyed to determine factors influencing the performance of PEs, including their attitudes towards conducting them. RESULTS: Responses from 118/192 (61%) psychiatrists showed that most (96%) believe that the PE is important. The majority (72%) indicated that their PE skills had diminished since working in psychiatry and this was reported more by senior psychiatrists compared to junior trainees (85 versus 40%). 77% considered that a patient's mental state should have a bearing on the type of PE the psychiatrist performs. CONCLUSIONS: Likely reasons for poor performance of PEs include: shortage of time and equipment, challenges associated with agitated or uncooperative patients, and possibly a degree of skill atrophy, especially in senior psychiatrists. Further research is needed to investigate if strategies addressing these factors would improve the standard of PEs on psychiatric patients.

The utility of the Edinburgh Depression Scale as a screening tool for depression in Parkinson's disease.

OBJECTIVE: This study aimed to evaluate the Edinburgh Depression Scale (EDS) as a screening tool for use in a Parkinson's disease (PD) population. Many commonly used depression scales include items relating to somatic symptoms that also occur in PD, which could potentially result in inaccurate reporting of depressive symptoms. The EDS is a scale that incorporates no somatic items. METHOD: One hundred twenty patients attending specialist PD clinics were assessed using a standardised diagnostic interview (Present State Examination--Schedules for Clinical Assessment in Neuropsychiatry) to establish a diagnosis of DSM-IV depression. They later completed the EDS with another researcher who was blind to the results of diagnostic interview. A receiver operating characteristic curve analysis was carried out to identify the optimal threshold score on the EDS and the Brief EDS to identify any depressive disorder or major depression. The performance characteristics at a range of thresholds were compared. RESULTS: A cut-off score of 10/11 gave maximal discriminant validity, with 74% sensitivity, 92% specificity and 64% positive predictive value for the identification of any depression according to DSM-IV criteria. CONCLUSIONS: This study suggests that the EDS is both a valid and potentially useful instrument that can be used as a quick self-completion questionnaire for screening for depression in people who have PD.

Fellowship Training in Arthroplasty Improves Treatment Success of Debridement, Antibiotics, and Implant Retention for Periprosthetic Knee Infections.

Background: Debridement, antibiotics, and implant retention (DAIR) is a well-accepted surgical strategy for periprosthetic joint infection (PJI) following total knee arthroplasty (TKA). DAIR in TKA may be incorrectly thought of as a "simple" procedure not requiring formal specialized training in arthroplasty. Currently, there are no studies comparing the risk of treatment failure based on surgeon fellowship training. Methods: A retrospective review was performed of consecutive patients who underwent DAIR for TKA PJI at our institution. Two cohorts were created based on whether DAIR was performed by an arthroplasty fellowship-trained (FT) surgeon or nonarthroplasty fellowship-trained (NoFT) surgeon. Primary outcome was treatment failure following DAIR at a minimum of 1 year postoperatively. Treatment failure was based on the Tier 1 International Consensus Meeting definition of infection control. Secondary outcomes were also recorded including death during the totality of PJI treatment. Results: A total of 112 patients were identified (FT = 68, NoFT = 44). At a mean follow-up of 7.3 years [standard deviation = 3.9], 73 patients (59.8%) failed treatment. Fellowship training in arthroplasty significantly improved treatment success rates (FT, 35/68 [51.5%]; NoFT, 10/44 [22.7%]; odds ratio 2.5 [95% confidence interval 1.1 to 5.9; P = .002]). Survivorship also differed significantly between the cohorts; at timepoints of 1.5 months, 5 months, 30 months, and 180 months, survivorship of the FT cohort was 79.4%, 67.6%, 54.4%, and 50.7%, respectively, compared with a survivorship of 65.9%, 52.3%, 25%, and 22.7% in the NoFT cohort (P = .002). Conclusions: TKA PJI treated with DAIR should not be considered a simple procedure. Improved treatment success may be associated with subspecialty fellowship training in arthroplasty. Level of Evidence: IV.

Mapping Staphylococcus aureus at Early and Late Stages of Infection in a Clinically Representative Hip Prosthetic Joint Infection Rat Model.

Prosthetic joint infection (PJI) continues to be a devastating complication following total joint replacement surgeries where Staphylococcus aureus is the main offending organism. To improve our understanding of the disease pathogenesis, a histological analysis of infected peri-implant tissue in a hip PJI rat model was utilized to assess S. aureus spread and tissue reaction at early and late stages of infection. Sprague-Dawley rats were used and received a left cemented hip hemiarthroplasty using a 3D-printed titanium femoral stem. The rats received an intra-articular injection of S. aureus Xen36. These infected rats were sacrificed either at 3 days post-infection (early-stage infection) or at 13-days post-infection (late-stage infection). The femoral and acetabular tissues of all animals were harvested at euthanasia. Histological analysis for the harvested tissue was performed using immunohistochemistry, hematoxylin and eosin, as well as Masson's trichrome stains. Histological examination revealed significant quantitative and qualitative differences in peri-implant tissue response to infection at early and late stages. This hip PJI rat model identified clear histologic differences between early and late stages of S. aureus infection and how quickly bacterial infiltration could occur. These findings can provide insight into why certain surgical strategies like debridement and antibiotics may be associated with high failure rates.

Anti-neutrophil cytoplasmic antibody (ANCA) associated small-vessel vasculitis in a patient with diabetic nephropathy and autoimmune polyendocrinopathy syndrome (APS) Type 2: a case report.

We present a 42-year-old woman with pre-existing autoimmune polyendocrinopathy syndrome (APS) Type 2 and chronic kidney disease due to Type 1 diabetic nephropathy, who developed a rapid deterioration in renal function due to perinuclear anti-neutrophil cytoplasmic antibody (pANCA)-associated vasculitis. Although possibly a chance occurrence, ANCA have been detected more frequently in patients with a history of certain autoimmune diseases. Such an association may simply reflect an underlying tendency to immune system dysfunction in these patients and the finding of positive ANCA serology does not reliably herald the development of ANCA-associated vasculitis. However, our case illustrates that positive ANCA serology in such circumstances is not always a benign phenomenon and should still be interpreted within the clinical context. Moreover, clinicians managing patients with pre-existing autoimmune disease should maintain a low threshold for appropriate assessment should such patients develop evidence suggestive of vasculitis.

Case series of physical examinations on psychiatric inpatients: Influence of a structured form on the quality of documentation.

BACKGROUND: There is a strong association between mental disorder and poor physical health. However, research indicates that the standard of physical examinations performed on psychiatric inpatients is not good. AIMS: This study aimed to assess the completeness of the physical examinations performed by psychiatric trainees on an acute psychiatric inpatient unit. METHOD: A retrospective analysis of 236 sets of inpatient case notes was performed. The quality of the documentation was assessed using a 50-point scoring system based on the presence or absence of reference to various items of examination. RESULTS: Eighty-five percent of the patients received a complete examination and 13% were not examined at all. The mean points score was only 20 out of 50, indicating that the overall standard of documentation was quite low. However, when a proforma was used rather than free text documentation, significantly more information was recorded. CONCLUSIONS: Most psychiatric patients are not receiving a thorough physical examination. An essential first step to address the problem would be to divide physical examinations into three categories according to the psychiatric setting and reach a consensus on a gold standard for each type. Standards could also be improved by the more widespread use of a well-designed proforma and greater supervision of psychiatric trainees' performance in this area.