Anatomical shoulder replacements in young patients: A systematic review and meta-analysis.

Introduction: Increasing numbers of young patients receive shoulder replacements. Greater information on outcomes is needed to inform implant choice. The aim of this study was to investigate the survivorship and clinical effectiveness of hemiarthroplasty and anatomical total shoulder arthroplasty (TSA) in patients younger than 65 years. Method: A systematic review was performed of MEDLINE, EMBASE, CENTRAL, The Cochrane Database of Systematic Reviews and National Joint Registry reports. The primary outcomes were implant survival and change in perioperative shoulder scores. Results: Meta-analysis of implant survivorship was performed of six studies reporting on 416 patients. Implant survival was 86.1% (72.1,100) at 10 years for hemiarthroplasty and 82.3% (64.6,100) for TSA. 20 year survival was 80.0% for hemiarthroplasty (72.5,87.4) and 75.0% (56.9,93.1) for TSA. Ten studies were included in the meta-analysis of shoulder scores, multiple instruments were used. The standardised mean difference between pre-operative and post-operative shoulder scores was 2.15 (1.95, 2.35) for TSA at 4.2-4.9 years, and 2.72 (1.98,3.47) for hemiarthroplasty at 3.8-6 years. Conclusion: Over 80% of shoulder replacements last more than 10 years, and 75% last more than 20 years. Significant improvements in shoulder scores are shown at all time points.

A type VI acromioclavicular joint injury: subcoracoid dislocation in a patient with polytrauma.

The Rockwood type VI acromioclavicular joint injury describes subcoracoid dislocation of the distal end of the clavicle. This injury pattern is exceedingly rare, with only 12 cases described in the literature. Diagnosis can be challenging; it is often the result of a high-energy mechanism and patients frequently have other severe distracting injuries. We report the case of a 23-year-old man who presented to our department after falling from a fifth-floor balcony. Alongside multiple intra-abdominal and musculoskeletal injuries, the patient sustained a type VI acromioclavicular joint dislocation. This injury was not picked up on the initial clinical assessment or described in the initial radiology report, with the diagnosis only made upon subsequent repeat review of the imaging by the admitting team. Fortunately, this delay did not increase the time to the patient receiving appropriate treatment. Despite its rarity, awareness of this injury pattern and its association with polytrauma is essential to reduce the risk of the diagnosis being overlooked in the acute setting.

When infection isn't infection.

Following open reduction and internal fixation for a proximal humerus fracture a 71-year-old man re-presented with wound changes consistent with infection and elevated inflammatory markers. No significant improvement was seen with concomitant intravenous antibiotics and multiple debridement procedures. This case was further complicated by soft tissue breakdown at the site of a left thigh haematoma also requiring debridement. Surgical site infections represent the most common cause of morbidity postoperatively. This case highlights the importance of considering a number of differential diagnoses. A diagnosis of pyoderma gangrenosum prompted systemic corticosteroid therapy giving rapid clinical improvement.

Addressing cardiometabolic risk in adults with spinal cord injury: acting now despite knowledge gaps.

This perspective advocates for the adoption of recently published clinical practice guidelines on identifying and managing cardiometabolic risk after spinal cord injury (SCI). It makes the case for acting now, with the knowledge that we currently have, while continuing to address knowledge gaps with high-quality research studies in this area. Cardiovascular disease is a leading cause of death in people with SCI. Cardiometabolic disease (CMD) and risks are more likely to be overlooked after SCI. Unique SCI-related considerations impact both assessment and management of cardiometabolic risk. Risk factors and components of CMD including obesity, impaired glucose tolerance/insulin resistance, dyslipidemia, and hypertension should be evaluated and managed to optimize the cardiometabolic health of this population. While it would be optimal to base all care on high-quality evidence-based research, its absence should not be an excuse for inaction. Applying what is currently known and filling the research gaps with empirical recommendations based on clinical rationale and expert consensus is both appropriate and necessary till more definitive SCI-specific evidence becomes available.

Hip fracture litigation: A 10-year review of NHS Litigation Authority data and the effect of national guidelines.

We present a review evaluating all litigation claims relating to hip fractures made in a 10-year period between 2005 and 2015. Data was obtained from the NHS Litigation Authority through a freedom of information request. All claims relating to hip fractures were reviewed. During the period analysed, 216 claims were made, of which 148 were successful (69%). The total cost of settling these claims was in excess of £5 million. The introduction of a best-practice tariff by the Department of Health in 2010 was designed to improve the quality of care for hip fracture patients. This was followed by guidance from the National Institute for Health and Clinical Excellence in 2011 and the British Orthopaedic Association in 2012. We analysed claims submitted before and after these guidelines were introduced and no significant difference in the number of claims was noted. The most common cause for litigation was a delay in diagnosis, which accounted for 86 claims in total (40%). Despite the presence of these guidelines and targets, there has not been a significant reduction in the number of claims or an improvement in diagnostic accuracy. This may be due to an increasing level of litigation in the UK but we must also question whether we are indeed providing best-practice care to our hip fracture patients and whether these guidelines need further review.

Trials based on specific fracture configuration and surgical procedures likely to be more relevant for decision making in the management of fractures of the proximal humerus: Findings of a meta-analysis.

OBJECTIVES: The objective of this study was to perform a meta-analysis of all randomised controlled trials (RCTs) comparing surgical and non-surgical management of fractures of the proximal humerus, and to determine whether further analyses based on complexity of fracture, or the type of surgical intervention, produced disparate findings on patient outcomes. METHODS: A systematic review of the literature was performed identifying all RCTs that compared surgical and non-surgical management of fractures of the proximal humerus. Meta-analysis of clinical outcomes was performed where possible. Subgroup analysis based on the type of fracture, and a sensitivity analysis based on the type of surgical intervention, were also performed. RESULTS: Seven studies including 528 patients were included. The overall meta-analysis found that there was no difference in clinical outcomes. However, subgroup and sensitivity analyses found improved patient outcomes for more complex fractures managed surgically. Four-part fractures that underwent surgery had improved long-term health utility scores (mean difference, MD 95% CI 0.04 to 0.28; p = 0.007). They were also less likely to result in osteoarthritis, osteonecrosis and non/malunion (OR 7.38, 95% CI 1.97 to 27.60; p = 0.003). Another significant subgroup finding was that secondary surgery was more common for patients that underwent internal fixation compared with conservative management within the studies with predominantly three-part fractures (OR 0.15, 95% CI 0.04 to 0.63; p = 0.009). CONCLUSION: This meta-analysis has demonstrated that differences in the type of fracture and surgical treatment result in outcomes that are distinct from those generated from analysis of all types of fracture and surgical treatments grouped together. This has important implications for clinical decision making and should highlight the need for future trials to adopt more specific inclusion criteria.Cite this article: S. Sabharwal, N. K. Patel, D. Griffiths, T. Athanasiou, C. M. Gupte, P. Reilly. Trials based on specific fracture configuration and surgical procedures likely to be more relevant for decision making in the management of fractures of the proximal humerus: Findings of a meta-analysisBone Joint Res 2016;5:470-480. DOI: 10.1302/2046-3758.510.2000638.

The cost of trauma operating theatre inefficiency.

The National Health Service (NHS) is currently facing a financial crisis with a projected deficit of £2billion by the end of financial year 2015/16. As operating rooms (OR) are one of the costliest components in secondary care, improving theatre efficiency should be at the forefront of efforts to improve health service efficiency. The objectives of this study were to characterize the causes of trauma OR delays and to estimate the cost of this inefficiency. A 1-month prospective single-centre study in St. Mary's Hospital. Turnaround time (TT) was used as the surrogate parameter to measure theatre efficiency. Factors including patient age, ASA score and presence of surgical and anaesthetic consultant were evaluated to identify positive or negative associations with theatre delays. Inefficiency cost was calculated by multiplying the time wasted with staff capacity costs and opportunity costs, found to be £24.77/minute. The commonest causes for increased TT were delays in sending for patients (50%) and problems with patient transport to the OR (31%). 461 min of delay was observed in 12 days, equivalent to loss of £951.58/theatre/day. Non-statistically significant trends were seen between length of delays and advancing patient age, ASA score and absence of either a senior clinician or an anaesthetic consultant. Interestingly, the trend was not as strong for absence of an anaesthetic consultant. This study found delays in operating TT to represent a sizable cost, with potential efficiency savings based on TT of £347,327/theatre/year. Further study of a larger sample is warranted to better evaluate the identified trends.

Cost analysis of the surgical treatment of fractures of the proximal humerus: an evaluation of the determinants of cost and comparison of the institutional cost of treatment with the national tariff.

AIMS: The aims of this study were to estimate the cost of surgical treatment of fractures of the proximal humerus using a micro-costing methodology, contrast this cost with the national reimbursement tariff and establish the major determinants of cost. METHODS: A detailed inpatient treatment pathway was constructed using semi-structured interviews with 32 members of hospital staff. Its content validity was established through a Delphi panel evaluation. Costs were calculated using time-driven activity-based costing (TDABC) and sensitivity analysis was performed to evaluate the determinants of cost RESULTS: The mean cost of the different surgical treatments was estimated to be £3282. Although this represented a profit of £1138 against the national tariff, hemiarthroplasty as a treatment choice resulted in a net loss of £952. Choice of implant and theatre staffing were the largest cost drivers. Operating theatre delays of more than one hour resulted in a loss of income DISCUSSION: Our findings indicate that the national tariff does not accurately represent the cost of treatment for this condition. Effective use of the operating theatre and implant discounting are likely to be more effective cost containment approaches than control of bed-day costs. TAKE HOME MESSAGE: This cost analysis of fractures of the proximal humerus reinforces the limitations of the national tariff within the English National Health Service, and underlines the importance of effective use of the operating theatre, as well as appropriate implant procurement where controlling costs of treatment is concerned.

Orthogeriatrics in the management of frail older patients with a fragility fracture.

This review article examines the role of orthogeriatric management for frail older patients with a fragility fracture. The history of orthogeriatrics and its application in clinical practice around the world is reported, and an evidence-based evaluation for the effect of orthogeriatric management on patient morbidity and mortality is also provided. It has been more than 50 years since the role of the geriatrician in the management of patients with a hip fracture was first described. The evidence that supports an orthogeriatric model of care has grown exponentially over the last decade. This evidence base is primarily related to hip fractures and demonstrates reduced morbidity and mortality rates amongst patients managed with a recognised model of orthogeriatric care. The societal and economic burden of hip fracture has led to health economic evaluations within this field, many of which have concluded that orthogeriatric management results in cost-effective clinical practice. Based on existing clinical and economic research, national clinical practice guidelines have been developed in several countries which recommend orthogeriatric participation in the management of older patients with a hip fracture. Compliance with such guidance has already demonstrated improved patient outcomes. Although the pathogenesis and prognosis of other types of fragility fracture may be as poor, there is a dearth of clinical research that evaluates the effect of orthogeriatric management on such injuries. Looking to the future, orthogeriatric management is likely to become more widespread, and the robust collection and reporting of patient outcomes from national registries will provide a greater understanding of the impact of orthogeriatric models in the care of all frail older patients with any type of fragility fracture.

Hip resurfacing arthroplasty at a non-specialist centre.

INTRODUCTION: Few studies have reported the outcome of hip resurfacing arthroplasty (HRA) with respect to implant characteristics from non-specialist centres. We report the survival, clinical and radiological outcomes of a single surgeon series of HRA with an average follow-up duration of five years. METHODS: All consecutive HRAs performed by a single surgeon between 2003 and 2011 at a district general hospital were retrospectively examined clinically and radiologically. RESULTS: A total of 85 patients underwent 109 HRAs (58 male [53.2%] and 51 female patients [46.8%]) with a mean follow-up period of 62 months (range: 12-102 months). The median age was 57 years (range: 25-75 years). The mean acetabular and femoral head component sizes were 54 mm (range: 48-64 mm) and 48 mm (range: 42-58 mm) respectively with a mean acetabular inclination angle of 42.9° (range: 20-75°). The survival rate was 95% with five revisions due to aseptic loosening (n=3) and fracture (n=2): these were predominantly for female patients (n=4), with significantly smaller mean acetabular (51 mm, p=0.04) and femoral (44 mm, p=0.02) implant sizes. Furthermore, they had a higher mean acetabular inclination angle of 48.1° (p=0.74). The mean Oxford hip score was 43.8 (range: 25-48) and the mean University of California Los Angeles (UCLA) activity score was 6.8 (range: 3-10). Radiological findings included heterotopic ossification in 13 (11.9%), radiolucent lines in 6 (5.5%), femoral neck thinning in 2 (1.8%) and femoral neck notching in 5 patients (4.6%). CONCLUSIONS: We have shown that HRA at a non-specialist centre has short to medium-term outcomes comparable with those at specialist centres. HRA therefore remains a viable option although vigilance is required in case selection and follow-up according to national guidance.

Quality assessment of guidelines on thromboprophylaxis in orthopaedic surgery.

We evaluated the quality of guidelines on thromboprophylaxis in orthopaedic surgery by examining how they adhere to validated methodological standards in their development. A structured review was performed for guidelines that were published between January 2005 and April 2013 in medical journals or on the Internet. A pre-defined computerised search was used in MEDLINE, Scopus and Google to identify the guidelines. The AGREE II assessment tool was used to evaluate the quality of the guidelines in the study. Seven international and national guidelines were identified. The overall methodological quality of the individual guidelines was good. 'Scope and Purpose' (median score 98% interquartile range (IQR)) 86% to 98%) and 'Clarity of Presentation' (median score 90%, IQR 90% to 95%) were the two domains that received the highest scores. 'Applicability' (median score 68%, IQR 45% to 75%) and 'Editorial Independence' (median score 71%, IQR 68% to 75%) had the lowest scores. These findings reveal that although the overall methodological quality of guidelines on thromboprophylaxis in orthopaedic surgery is good, domains within their development, such as 'Applicability' and 'Editorial Independence', need to be improved. Application of the AGREE II instrument by the authors of guidelines may improve the quality of future guidelines and provide increased focus on aspects of methodology used in their development that are not robust.

Hypertension and antihypertensive treatment in veterans with spinal cord injury and disorders.

OBJECTIVES: Hypertension (HTN) is an important risk factor for cardiovascular disease, a major cause of morbidity and mortality among people with spinal cord injury and disorders (SCI/D). Our study examined prevalence, associated factors, and pharmacological treatment of HTN in Veterans with SCI/D compared with a matched control group. METHODS: A retrospective review was conducted of Veterans with traumatic SCI/D (TSCI/D; n=6672), non-traumatic SCI/D (NTSCI/D; n=3566) and a matched, non-injured cohort. RESULTS: Over half of patients with TSCI/D (56.6%) had HTN, compared with 68.4% of matched controls (P<0.001). Paraplegic and tetraplegic Veterans with TSCI/D had significantly lower odds of having a HTN diagnosis compared with control (odds ratios (OR)=0.84 (0.77-0.91); OR=0.38 (0.35-0.42)). About 71.8% of patients with NTSCI/D had HTN compared with 72.3% of matched controls (P>0.05). Paraplegic and tetraplegic Veterans with NTSCI/D did not have significantly different odds of a HTN diagnosis compared with control (OR=0.92 (0.79-1.05); OR=0.85 (0.71-1.01)). Adjusted analysis indicates that Veterans with tetraplegia and HTN were less likely to receive antihypertensive therapy (TSCI/D, OR=0.62 (0.53-0.71); NTSCI/D, OR=0.81 (0.66-0.99)). CONCLUSION: HTN appears to be more prevalent in SCI/D Veterans than previously reported. TSCI/D Veterans have a significantly lower prevalence of HTN whereas NTSCI/D Veterans have a comparable prevalence of HTN to those without SCI/D. The level of injury (tetraplegia vs paraplegia) has a large impact on the prevalence of HTN in the traumatic cohort. Subsequent antihypertensive therapy is used less in both TSCI/D and NTSCI/D Veterans with tetraplegia and more in TSCI/D Veterans with paraplegia.

Development of adsorbent from Teflon waste by radiation induced grafting: equilibrium and kinetic adsorption of dyes.

Mutual radiation grafting technique was employed to graft polyacrylic acid (PAA) onto Polytetrafluoroethylene (Teflon) scrap using high energy gamma radiation. Polyacrylic acid-g-Teflon (PAA-g-Teflon) adsorbent was characterized by grafting extent measurement, FTIR spectroscopy, SEM and wet ability & surface energy analysis. The PAA-g-Teflon adsorbent was studied for dye adsorption from aqueous solution of basic dyes, namely, Basic red 29 (BR29) and Basic yellow 11 (BY11). The equilibrium adsorption data were analyzed by Langmuir and Freundlich adsorption isotherm models, whereas, adsorption kinetics was analyzed using pseudo-first order, pseudo-second order and intra-particle diffusion kinetic models. Equilibrium adsorption of BR29 was better explained by Langmuir adsorption model, while that of BY11 by Freundlich adsorption model. The adsorption capacity for BY11 was more than for BR29. Separation factor (R(L)) was found to be in the range 0 < R(L) < 1, indicating favorable adsorption of dyes. Higher coefficient of determination (r(2) > 0.99) and better agreement between the q(e,cal) and q(e,exp) values suggested that pseudo-second order kinetic model better represents the kinetic adsorption data. The non-linearity obtained for intra-particle diffusion plot indicated, more than one process is involved in the adsorption of basic dyes. The desorption studies showed that ~95% of the adsorbed dye could be eluted in suitable eluent.

Decoloration and degradation of Reactive Red-120 dye by electron beam irradiation in aqueous solution.

The decoloration and degradation of aqueous solution of the reactive azo dye viz. Reactive Red-120 (RR-120) was carried out by electron beam irradiation. The change in decoloration percentage, removal of chemical oxygen demand (COD) and total organic carbon (TOC), solution pH and five-day biochemical oxygen demand (BOD(5)) were investigated with respect to the applied dose. However, the concentration of the dye in the solution showed a great influence on all these observables. During the radiolysis process, it was found that the decoloration of dye was caused by the destruction of the chromophore group of the dye molecule, whereas COD and TOC removal were depended on the extent of mineralization of the dye. The decrease in pH during the radiolysis process indicated the fragmentation of the large dye molecule into smaller organic components mostly like smaller organic acids. The BOD(5)/COD ratio of the unirradiated dye solution was in the range of 0.1-0.2, which could be classified as non-biodegradable wastewater. However, the BOD(5)/COD ratio increased upon irradiation and it indicated the transformation of non-biodegradable dye solution into biodegradable solution. This study showed that electron beam irradiation could be a promising method for treatment of textile wastewater containing RR-120 dye.

Evaluation of the efficiency and throughput of a gamma irradiator treating municipal sewage sludge.

Sludge Hygienisation Research Irradiator (SHRI) Facility at Vadodara (India) has been disinfecting liquid sewage sludge with (60)Co gamma rays since 1992. At some point, the radiation process was modified from its originally designed closed-loop system to an open-loop system. Dosimetry experiments were performed to estimate absorbed doses to the sludge for different periods of irradiation of a 15m(3) batch in an open-loop irradiation process. The paper reports the dosimetry results and evaluated operational parameters of the irradiator, namely, effective dose rate in the open-loop system, irradiation efficiency, and throughput. Also, the open-loop system and the closed-loop system are compared in terms of the effective dose rate.

Swelling response of radiation synthesized 2-hydroxyethylmethacrylate-co-[2-(methacryloyloxy)ethyl] trimethylammonium chloride hydrogels under various in vitro conditions.

High-energy (60)Co gamma radiation has been used to synthesize 2-hydroxyethylmethacrylate-co-[2-(methacryloyloxy)ethyl]trimethylammonium chloride (HEMA-co-MAETC) polyelectrolyte hydrogels. HEMA-co-MAETC co-polymer gels were characterized and investigated for swelling behaviour in different swelling conditions. Fourier transformed infrared spectroscopy (FT-IR) and scanning electron microscopy (SEM) techniques were used to characterize the co-polymer gels. Swelling extent of the gels was found to be a linear function of MAETC content in the gels. The effect of ionic strength, temperature, pH, some solutes of biological importance like glucose, urea, and surfactants such as Triton-X and deoxycholic acid on swelling behavior have been reported. The swelling of gels at higher temperature enhanced the swelling rates but not the swelling extent. HEMA-co-MAETC hydrogel exhibited an excellent responsive characteristic to the ionic strength of the swelling medium. It was found that the swelling of the co-polymer gel at 60 degrees C reduced the swelling-deswelling cycle time by approx. 30% without altering the swelling extent. The gels were also investigated for their swelling in aqueous solutions of anionic dyes, acid blue 25 (AB25), acid blue (AB74) and acid yellow 99 (AY99), and were found to be suitable for dye uptake applications.

Neural and anatomical abnormalities of the gastrointestinal system resulting from contusion spinal cord injury.

Gastrointestinal (GI) abnormalities resulting from spinal cord injury (SCI) are challenging disorders that have not been examined experimentally using clinically relevant models. In this study, female Sprague-Dawley rats (n=5/groupx4: T10-T11 contusion, laminectomy, or naïve) were fasted for 24 h before being submitted to dye recovery assays (Phenol Red solution, 1.5 ml/rat; per oral) on GI emptying/transiting at 48 h or 4 weeks postinjury (p.i.). Compared with controls, SCI significantly increased dye recovery rate (DRR, determined by spectrophotometry) in the duodenum (+84.6%) and stomach (+32.6%), but decreased it in the jejunum (-64.1% and -49.5%) and ileum (-73.6% and -70.1%) at 48 h and 4 weeks p.i., respectively (P

1, 25-Dihydroxycholecalciferol (1,25-(OH)(2) D(3)) levels in osteoporosis.

In the present study primary involution osteoporosis and vitamin D levels were studied in 60 subjects including thirty controls. The biochemical analysis of serum calcium, phosphorus, ALP, albumin and vitamin D(3) (1,25-(OH)(2) D(3)) levels were significantly decreased in osteoporotic patients when compared to non-osteoporotic control group. There was a significant correlation of magnitude of sun exposure with 1,25-(OH)(2) D(3) levels. Similarly, vitamin D intake in the diet has a significant correlation with 1,25-(OH)(2) D(3) concentration. However, no correlation could be obtained between vitamin D(3) levels with increasing age. Among the biochemical markers serum calcium, phosphorus, ALP and albumin could not be correlated with 1,25-(OH)(2) D(3) levels.

Radiation chemical studies on thermosensitive N-isopropylacrylamide and its polymer in aqueous solutions.

The pulse radiolysis technique has been employed to determine the initiation and propagation rates of different transient species involved in the polymerization of N-isopropylacrylamide (NIPA) in aqueous solutions. Polymerization by anionic mechanism has been observed to be faster than by the free-radical mechanism. The kinetic, spectroscopic and redox properties of the transient species formed upon reaction of primary radiolytic species of water radiolysis with NIPA have been evaluated. The one-electron oxidation potential for the formation of a radical cation is quite high (>2 V), but the one-electron reduction potential is low (in the range of -0.3 to -0.7 V). The radical anion of NIPA is able to undergo an electron-transfer reaction with MV(2+), and has a pK(a) value of 3.2. The tert-butyl alcohol radical was also able to initiate polymerization. Gamma radiation-induced polymerization studies showed that the reaction of H(.)/(.)OH/e(aq)(-)/tert-butyl alcohol radicals with NIPA results in a nearly equal yield of the gel fraction. The hydrogel is observed to have very little swelling below pH 3 and above pH 10. The linear polymer of NIPA formed by irradiating dilute aqueous solution is found to be a thermosensitive polymer with lower a critical solution temperature (LCST) of ~33 degrees C. The diameters of polymer molecules were 290 and 20 nm at temperature below and above LCST, respectively.