The utility of cemented femoral stems in modern THA: a 10-year comparative analysis of the Charnley and Exeter stems.

BACKGROUND: Total hip replacement (THR) is one of the most common surgical procedures performed worldwide. The controversy surrounding the relative merits of a cemented composite beam or cemented taper-slip stem in total hip replacement continues. Our aims primarily were to assess the 10-year outcomes of cemented stems using Charnley and Exeter prostheses with regional registry data and secondarily to assess the main predictors of revision. METHODS: We prospectively collected registry data for procedures performed between January 2005 and June 2008. Only cemented Charnley and Exeter stems were included. Patients were prospectively reviewed at 6 months, 2, 5 and 10 years. The primary outcome measure was a 10-year all-cause revision. Secondary outcomes included 're-revision', 'mortality' and functional 'Western Ontario and McMaster Universities Osteoarthritis Index' (WOMAC) scores. RESULTS: We recorded a total of 1351 cases in the cohort, 395 Exeter and 956 Charnley stems. The overall all-cause revision rate at 10 years was 1.6%. The revision rate for Charnley stem was 1.4% and 2.3% revision rate for all Exeter stems with no significant difference noted between the two cohorts (p = 0.24). The overall time to revision was 38.3 months. WOMAC scores at 10 years were found to be insignificantly higher for Charnley stems (mean 23.8, σ = 20.11) compared to Exeter stems (mean 19.78, σ = 20.72) (p = 0.1). CONCLUSION: There is no significant difference between cemented Charnley and Exeter stems; they both perform well above the international average. The decline in the use of cemented THA is not fully supported by this regional registry data.

Revision of total knee replacement (TKR) secondary to raised cobalt levels: should this be considered in the painful TKR patient?

A 63-year-old woman was referred to the specialised knee revision clinic with ongoing knee pain after total knee replacement. She incidentally had cobalt and chromium levels measured. These were seen to be elevated. Comprehensive assessment and investigation did not identify any other source of cobalt or chromium. Aseptic loosening of the knee was diagnosed, and the knee was revised. At the time of surgery, the tissue was seen to be darkened consistent with metallosis. Multiple samples excluded infection on extended cultures. Aspirated fluid showed that periprosthetic fluid had elevated cobalt levels. The knee was successfully revised with good symptomatic outcome and significantly, over the course of several months post-revision, the cobalt and chromium levels returned to normal.

Tempering hope with Intimate Knowledge: Contrasting emergences of the concept 'uninfectious' in HIV.

In this paper, we contrast two emergences of the concept of 'uninfectious' (that pharmaceuticals can render someone living with HIV non-infectious) in HIV. First, using Novas' framing of 'political economies of hope', we describe the deployment of 'uninfectious' as part of global health campaigns. Second, we draw on Raffles' (International Social Science Journal, 2002, 54, 325) concept of 'intimate knowledge' to theorise our own account of 'uninfectious' through a re-analysis of qualitative data comprising the intimate experiences of people living with or around HIV collected at various points over the last 25 years. Framed as intimate knowledge, 'uninfectious' becomes known through people's multiple engagements with and developing understandings of HIV over a prolonged period. As contingent and specific, intimate knowledge does not register within the biomedical/scientific ontological system that underpins discourses of hope employed in global campaigns. The concept of intimate knowledge offers the potential to critique discourses of hope in biomedicine problematising claims to universality whilst enriching biomedical understandings with accounts of affective, embodied experience. Intimate knowledge may also provide a bridge between different epistemological traditions in the sociology of health and illness.

Regional trauma patterns during the COVID-19 pandemic.

BACKGROUND: The current pandemic has impacted heavily on health systems, making unprecedented demands on resources, and forcing reconfiguration of services. Trauma and orthopaedic units have cancelled elective surgery, moved to virtual based clinics and have been forced to reconsider the provision of trauma. Our national elective orthopaedic centre has been re-designated as a trauma centre to allow tertiary centres re-direct triaged trauma. Many governments, as part of their COVID-19 management, have significantly restricted activity of the general population. We proposed that trauma patterns would change alongside these changes and maintaining existing standards of treatment would require dedicated planning and structures. METHODS: Referrals over a six-week period (March 15th to April 30th) were retrospectively reviewed. Data was collected directly from our referral database and a database populated. Analysis was performed to assess trauma volume, aetiology, and changes in trends. RESULTS: There were one hundred and fifty-nine referrals from three individual hospitals within the timeframe. Mean age of patient's referred was 55 (range17-92). Males accounted for 45% of cases. F&A injuries were the most common (32%), followed by H&W (28%), UL (17%), H&F (16%) and K&T (7%). In comparison to the corresponding time-period in 2019, trauma theatre activity reduced by almost one half (45.3%) CONCLUSION: The majority of trauma referred to our Dublin based centre during COVID-19 related population restrictions appears to be home based and trauma volumes have decreased. Significant reductions are apparent in work and sport related injuries suggestive of compliance with COVID-19 activity guidelines. Maintaining existing standards of treatment requires dedicated planning.

Crisis change management during COVID-19 in the elective orthopaedic hospital: Easing the trauma burden of acute hospitals.

INTRODUCTION: With the emergence of the 2019 novel coronavirus and its resulting pandemic status in March 2020 all routine elective orthopaedic surgery was cancelled in our institution. The developing picture in Italy, of acute hospitals becoming overwhelmed with treating patients suffering with severe and life-threatening symptoms from the disease, prompted the orthopaedic surgeons to formulate a plan to transfer trauma patients requiring surgery to the elective hospital to unburden the acute hospital system. METHODS: Under the threat of this pandemic; protocols and algorithms were established for referral, acceptance and care of trauma patients from acute hospitals in the region. Each day, as new guidance on COVID-19 emerged, our process and algorithms were adjusted to reflect pertinent change. RESULTS: The screening of all patients referred, worked well in keeping our hospital "COVID-free" with respect to patients undergoing operations. An upward trend in cases referred reflected the decreased capacity in the acute hospitals due to rising cases of COVID-19 within the hospital network. During the first 7 weeks of the pandemic 308 operations were performed, (31.1% upper limb, 33.4% lower limb, 4.1% spine, 14.1% urgent elective, 17.4% plastic surgery cases). Regular review and audit of the activity in the hospital as well as communication with the referring teams enabled appropriate planning to accommodate the increase in case-mix as the need arose. DISCUSSION: This paper details the steps that were taken in planning for such a change in management specific to the orthopaedic surgery setting and the lessons learnt during this process. The success of the development of this pathway was facilitated by clear communication channels, flexibility to adapt to changing process and feedback from all stakeholders. The implementation of this pathway allowed the unburdening of acute hospitals dealing with the pandemic that was steadily reducing access to operating theatres and anaesthetic resources.

Bypass: an integrated hip fracture care pathway.

BACKGROUND: The incidence of hip fractures is expected to increase over the coming years, placing a greater burden on limited resources. A high volume of patients is brought to hospitals that do not have the resources necessary to provide definitive care. Optimal care involves a coordinated and integrated system of trauma care. The hip fracture care pathway introduced between a referring peripheral hospital and our institution represents a coordinated multidisciplinary approach to patient care. AIMS: To describe and report on the outcomes over an 18-month period of the integrated hip fracture care pathway between referring peripheral hospitals and our institution. METHODS: A retrospective analysis of the prospectively maintained hip fracture database over an 18-month period. RESULTS: Between March 2017 and September 2018, 86 consecutive patients were referred to our institution through a new referral pathway. Of these, 69 patients came from the Emergency Department of the referring hospital and 17 arrived via bypass. All 86 patients were managed on a specialist orthopaedic ward. The average length of stay was 4.28 days, with maximum of 13 and minimum of 2 days. Over 84% of patients underwent definitive treatment within 48 h of a diagnosed hip fracture. DISCUSSION: The fragmented approach to the management of trauma patients both in a pre-hospital and hospital care setting is a cause for concern. Our integrated hip fracture referral pathway, incorporating bypass of the referring hospital, represents a multidisciplinary care pathway for the management of patients with fractured neck of femur and can have potential benefits including improved patient outcomes, allowing the optimal allocation of resources and providing training opportunities.

Failed osteosynthesis of cemented B1 periprosthetic fractures.

BACKGROUND: Periprosthetic fractures about the hip are increasingly common. The literature estimates a failure rate of approximately 10% in Vancouver B1 type fractures which have undergone fixation. There is currently no guidance available on the next step of management for this patient group. This study presents a series of nine Vancouver B1 fractures with failed osteosynthesis and proposes that repeated fixation has poorer results than revision. METHODS: A total of nine patients (five women, four men) with a mean age of 71.2 years (52-83) underwent operative treatment for failed osteosynthesis of periprosthetic fractures of Vancouver type B1. Three patients were revised to a long revision stem while six patients had repeated osteosythesis. Failure was defined as the need for further operative intervention. RESULTS: The three patients revised to a long revision stem at first failure of osteosynthesis required no further surgical intervention. All six patients who had repeat osteoynthesis failed again. Five patients were subsequently successfully treated with revision of the primary stem, three were revised to a long revision stem while two patients required proximal femoral replacement. One patient died prior to revision. The mean follow up following initial B1 fracture was 49.3 months and following definitive operative intervention was 37.7 months. Six patients had died at 1st July 2017. CONCLUSION: Failed osteosynthesis of B1 fractures may necessitate revision rather than repeat fixation, regardless of how well fixed the stem appears. Revision to a long stem provided good results in this cohort.

Radiographic and Functional Outcomes following Knee Arthrodesis Using the Wichita Fusion Nail.

The purpose of this study was to report both the radiographic and functional outcomes of patients undergoing knee arthrodesis with the Wichita Fusion Nail (WFN) within the Republic of Ireland and compare the results to existing literature. Patient charts and radiographs were reviewed on all patients who had a WFN implanted in Ireland to date. Patients were invited to complete a Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score as a functional assessment. Twenty-three patients were identified. Patients had an average of 8 (range: 0-26) knee surgeries prior to arthrodesis. The most common indication was failed arthroplasty due to recalcitrant infection (69.5%). Successful fusion occurred in 60.8% of patients. The mean time to fusion was 9.21 months. The mean WOMAC score was 58.55 with a range of 31 to 96. We found a rate of arthrodesis lower than that reported in other published series. However, the rate of major complications was comparable to those published previously, reflecting the often-challenging patient cohort. Our study shows that the WFN should not be viewed as a near-universally successful option to salvage an unreconstructable knee.

The art of presenting - Failures, fonts and the future.

Many of you, like me, will have given countless presentations throughout your career and to wide and varied audiences. I too, like many of you, have never been formally taught how to present, if that is such a thing. So, I got to thinking: in any case, who are "expert presenter" teachers? Some people have it and some people do not - right? In this short piece, I explore what it is to present, how this evolves, and try to pin down the why rather than the how and give you a little insight into my haphazard journey along this process.

A Rare Case of Bilateral Patellar Tendon Ruptures: A Case Report and Literature Review.

Bilateral patellar tendon ruptures are rare. The majority of case reports describing bilateral patellar tendon ruptures have occurred in patients with predisposing factors to tendinopathy. We describe a case of bilateral patellar tendon rupture sustained following minimal trauma by a patient with no systemic disease or history of steroid use. Due to the rarity of this injury, clinical suspicion is low. It is reported that 38% of patellar tendon ruptures are misdiagnosed initially. Therefore careful history taking and physical examination is integral in ensuring a diagnosis is achieved for early primary repair. We discuss the aetiology of spontaneous tendon rupture and report a literature review of bilateral patellar tendon ruptures.

Being targeted: Young women's experience of being identified for a teenage pregnancy prevention programme.

Research on the unintended consequences of targeting 'high-risk' young people for health interventions is limited. Using qualitative data from an evaluation of the Teens & Toddlers Pregnancy Prevention programme, we explored how young women experienced being identified as at risk for teenage pregnancy to understand the processes via which unintended consequences may occur. Schools' lack of transparency regarding the targeting strategy and criteria led to feelings of confusion and mistrust among some young women. Black and minority ethnic young women perceived that the assessment of their risk was based on stereotyping. Others felt their outgoing character was misinterpreted as signifying risk. To manage these imposed labels, stigma and reputational risks, young women responded to being targeted by adopting strategies, such as distancing, silence and refusal. To limit harmful consequences, programmes could involve prospective participants in determining their need for intervention or introduce programmes for young people at all levels of risk.

Learning from the experiences of people with HIV using general practitioner services in London: a qualitative study.

UNLABELLED: Aim To explore the experiences of people with HIV (PWHIV) using general practitioner (GP) services in order to identify barriers to use. BACKGROUND: Traditionally, GPs have little involvement in the care of PWHIV. However, as HIV becomes a chronic condition and the population of PWHIV ages, there is a need to increase this involvement. Despite high levels of GP registration, the majority of PWHIV in London report that their GP is not involved in their HIV care. METHODS: This paper presents qualitative findings from a mixed method study of PWHIV's experiences of clinical services. Survey respondents were purposively sampled to recruit 51 PWHIV who took part in eight focus groups. Participants were asked about their experience of using GP services. Findings Three factors emerged which mediated experiences of GP care. Competence: respondents were concerned about the potential for misdiagnosis of symptoms, lack of awareness of the health needs of PWHIV and experiences of prescribing, which could lead to drug interactions. Continuity: not being able to get appointments quickly enough, not being able to see the same doctor twice and not being able to keep the same GP when one changed address were experienced as impediments to use. Communication: lack of communication between GPs and HIV specialists led to what participants called 'patient ping-pong' where they found themselves acting as a go-between for different clinical specialists trying to make sense of their care. CONCLUSION: Meaningful contact between HIV specialists and GPs is likely to allay concerns about competency as treatment and care decisions can be taken collaboratively between the GP, HIV specialist and patient. A key component of acceptable GP care for PWHIV is likely to be the application of long-term condition management approaches, which includes empowered patient self-management.

Non-condom related strategies to reduce the risk of HIV transmission: Perspectives and experiences of gay men with diagnosed HIV.

Gay men with diagnosed HIV can adopt a number of strategies to reduce the risk of transmitting HIV to others, although research has typically focussed on condom use. Interviews with 42 HIV-positive gay men who reported recent engagement in anal intercourse without condoms explored their awareness of sexual risk and their perceptions of non-condom-related strategies to reduce it. In articulating men's ambivalence for strategies that can only reduce the risk of transmission, rather than eliminating, the findings have implications for the consideration and integration of new biomedical interventions to reduce the likelihood of HIV transmission.

Periprosthetic Fractures About the Hip: A Case-Matched Retrospective Analysis of Functional Outcomes Postrehabilitation.

INTRODUCTION: Little research has examined postrehabilitation functional outcomes of periprosthetic hip fractures. Predicted functional deficits and acceptable rehabilitation outcomes for these patients are not established. This study aimed to compare functional outcomes of periprosthetic fractures to matched patients with total hip arthroplasty (THA). MATERIALS AND METHODS: Cases with periprosthetic fracture (PPF) were matched for age, gender, and surgeon to primary THA cases. Only patients who had completed at least 1 year of rehabilitation were included. Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores were calculated for all surviving cases with PPF and primary THA. Secondary outcomes included length of stay and mortality. Statistical analysis was performed using Microsoft Excel and the 2-tailed Wilcoxon signed rank test. A P value of <.05 was accepted as indicative of statistical significance. RESULTS: We identified 25 patients with PPF. Three patients were unsuitable for functional assessment. Of the cases with PPF suitable for functional assessment, 14 (14/22) were male. The median age of the PPF and the THA groups was 71 years and 68 years respectively. The median WOMAC score for the PPF group was 26 (interquartile range [IQR] 5.5-49.5) compared to that of the primary THA group, 3 (IQR 2.0-24.5; P < .05). In the PPF group, there were 7 deaths and 3 of the surviving patients had significant complications. The median length of stay in the PPF group was 13 days (IQR 10.5-35) compared to the matched group of 5 days (IQR 5-8.5; P < .05). CONCLUSION: Patients with PPF have markedly poorer functional outcomes than age-, gender-, and surgeon-matched patients with THA as well as prolonged length of stay. Future research should target the identification of factors that may improve functional outcomes in this growing cohort.

Pharmaceutical HIV prevention technologies in the UK: six domains for social science research.

The development of pharmaceutical HIV prevention technologies (PPTs) over the last five years has generated intense interest from a range of stakeholders. There are concerns that these clinical and pharmaceutical interventions are proceeding with insufficient input of the social sciences. Hence key questions around implementation and evaluation remain unexplored whilst biomedical HIV prevention remains insufficiently critiqued or theorised from sociological as well as other social science perspectives. This paper presents the results of an expert symposium held in the UK to explore and build consensus on the role of the social sciences in researching and evaluating PPTs in this context. The symposium brought together UK social scientists from a variety of backgrounds. A position paper was produced and distributed in advance of the symposium and revised in the light this consultation phase. These exchanges and the emerging structure of this paper formed the basis for symposium panel presentations and break-out sessions. Recordings of all sessions were used to further refine the document which was also redrafted in light of ongoing comments from symposium participants. Six domains of enquiry for the social sciences were identified and discussed: self, identity and personal narrative; intimacy, risk and sex; communities, resistance and activism; systems, structures and institutions; economic considerations and analyses; and evaluation and outcomes. These are discussed in depth alongside overarching consensus points for social science research in this area as it moves forward.

Total knee replacement under tourniquet control: A prospective study of the peripheral arterial vasculature using colour-assisted duplex ultrasonography.

BACKGROUND AND PURPOSE: A tourniquet may potentiate rare and devastating arterial complications after total knee replacement (TKR) in patients with peripheral vascular disease (PVD). Most prior studies that evaluated peripheral arterial blood flow primarily used the ankle-brachial index (ABI). METHODS: We assessed the prevalence and risk factors for PVD in a cohort undergoing TKR. Clinical and radiological evaluations, including duplex ultrasonography, were performed one week prior to, and six weeks post-TKR performed under tourniquet control. Forty patients were analysed (20 male, 20 female; mean age 67 yrs, range: 53-80 yrs). MAIN FINDINGS: Hypertension (50%) and hypercholesterolaemia (50%) were the most common co-morbidities. Distal pulses were present in all patients preoperatively. Six patients (15%) had arterial calcification on their preoperative knee X-rays. Three patients (7.5%) had moderate PVD. There was no change in blood flow postoperatively in patients with or without PVD (p > 0.05). Vascular stenosis was less than 50% in all patients preoperatively and postoperatively. No postoperative vascular complications occurred. CONCLUSIONS: Severe PVD is not common in patients undergoing TKR. Performing total knee replacement under tourniquet control does not adversely affect the vasculature in patients with less than 50% vascular occlusion.

Implant failure caused by non-union of bisphosphonate-associated subtrochanteric femur fracture.

Bisphosphonate use has been identified as a contributory factor in atypical subtrochanteric fracture of the femur. These fractures are commonly treated with an intramedullary device. We present a case of implant failure of an intrameduallary device caused by non-union of an atypical subtrochanteric fracture.

The conundrum of calcaneal spurs: do they matter?

BACKGROUND: Chronic plantar heel pain is a common and potentially debilitating condition, often caused by plantar fasciitis. Plantar calcaneal spurs were originally considered the cause of plantar fasciitis but are now regarded as an incidental finding by most authors. We aimed to test this hypothesis and to investigate predisposing factors for the development of spurs. METHODS: We reviewed all lateral ankle X rays taken in our institution over a 6-month period and identified all X rays demonstrating calcaneal spurs. Then, we identified a similar number of age- and sex-matched controls without spurs. We contacted both groups by telephone and compared symptoms of heel pain, plantar fasciitis, associated comorbidities, and foot and ankle outcome scores (FAOSs). RESULTS: We reviewed the X rays of 1103 consecutive patients and found a spur prevalence of 12.4%, more common in women and older patients. Questioning of the spur group and control group found a higher body mass index in the spur group. Patients with spurs were 4 times more likely to have diabetes mellitus and 10 times more likely to have lower-limb osteoarthritis. Patients with spurs had more foot pain and poorer FAOS than the control group, even when patients with plantar fasciitis were excluded. CONCLUSION: Our results demonstrate that the presence of a plantar calcaneal spur may be an indicator of foot pain independent of plantar fasciitis. Although spurs may not cause foot pain themselves, they may be an indication of other associated conditions. CLINICAL RELEVANCE: We have demonstrated the relevance of a radiographic finding once considered irrelevant.