Long-Term Trajectory of Recovery Following Pilon Fracture Fixation.

OBJECTIVES: To describe the trajectory of recovery following fixation of pilon fractures from baseline to 5-year follow-up. DESIGN: Prospective cohort study. SETTING: Level-1 trauma center. PATIENTS/PARTICIPANTS: Patients with pilon fractures (OTA/AO 43.C) treated with open reduction and internal fixation. INTERVENTION: None. MAIN OUTCOMES MEASURES: Patient-reported outcome measures were measured at baseline, 6 months, 1 year, and 5 years using the Short-Form 36 Health Survey (SF-36) Physical Component Score and Mental Component Score, Short Musculoskeletal Functional Assessment, and the Foot and Ankle Outcome Score. RESULTS: One hundred two patients were enrolled: mean age was 42.6 years; 69% were males; 88% had an injury severity score of 9; 74 patients (73%) completed 1-year follow-up; 40 patients (39%) completed 5-year follow-up. Trajectory of recovery of physical function showed a significant decline between baseline and 6 months, with significant improvement between 6 months and 1 year and then ongoing but slower improvement between 1 year and 5 years. Sixty-four patients returned to baseline SF-36 Physical Component Score at 5 years. Pain was a persistent issue and remained significantly worse at 5 years when compared with baseline. Psychological well-being (SF-36 Mental Component Score) did not significantly change from baseline at 5 years. CONCLUSION: Functional recovery following open reduction and internal fixation for pilon fractures was characterized by an initial decrease in function from baseline, followed by an increase between 6 months and 1 year, and then slower but continued increases from 1 year to 5 years. Function did not return to baseline levels, pain was a persistent issue, and mental well-being showed no change from baseline at 5 years. This information may be useful when counselling patients. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Revision total knee arthroplasty versus primary total knee arthroplasty: a matched cohort study.

INTRODUCTION: The primary aim of this study was to describe a baseline comparison of early knee-specific functional outcomes following revision total knee arthroplasty (TKA) using metaphyseal sleeves with a matched cohort of patients undergoing primary TKA. The secondary aim was to compare incidence of complications and length of stay (LOS) between the two groups. METHODS: Patients undergoing revision TKA for all diagnoses between 2009 and 2016 had patient-reported outcome measures (PROMs) collected prospectively. PROMs consisted of the American Knee Society Score (AKSS) and Short-Form 12 (SF-12). The study cohort was identified retrospectively and demographics were collected. The cohort was matched to a control group of patients undergoing primary TKA. RESULTS: Overall, 72 patients underwent revision TKA and were matched with 72 primary TKAs with a mean follow-up of 57 months (standard deviation (SD) 20 months). The only significant difference in postoperative PROMs was a worse AKSS pain score in the revision group (36 vs 44, p = 0.002); however, these patients still produced an improvement in the pain score. There was no significant difference in improvement of AKSS or SF-12 between the two groups. LOS (9.3 days vs 4.6 days) and operation time (1 hour 56 minutes vs 1 hour 7 minutes) were significantly higher in the revision group (p < 0.001). Patients undergoing revision were significantly more likely to require intraoperative lateral release and postoperative urinary catheterisation (p < 0.001). CONCLUSION: This matched-cohort study provides results of revision TKA using modern techniques and implants and outlines what results patients can expect to achieve using primary TKA as a control. This should be useful to clinicians counselling patients for revision TKA.

Consent in forefoot surgery; What does it mean to the patient?

AIMS: This study aimed to assess patient risk recall and find risk thresholds for patients undergoing elective forefoot procedures. METHODS: Patients were interviewed in the pre-assessment clinic (PAC) or on day of surgery (DOS); some in both settings. A standardised questionnaire was used for all interviews, regardless of setting. Patients were tested on which risks they recalled from their consent process, asked for thresholds for five pre-chosen risks and asked about a sham risk. RESULTS: Across all interviews, risk recall on DOS (2.34 risks/patient interview) was significantly lower (p=.05) than in PAC (2.95 risks/patient interview) - this was repeated when comparing results from patients interviewed in both settings only with PAC mean recall of 2.93 risks/patient interview and DOS mean recall of 2.57 risks/patient interview. The mean reported risk thresholds greatly exceeded NHS Lothian's observed complication rates for forefoot procedures. The five risks tested for thresholds produced the same order in each interview setting, suggesting a patient-perceived severity ranking. Patients answering the sham risk question incorrectly tended to recall fewer risks across all interviews. CONCLUSIONS: This study shows that patient risk recall is poor, as previous literature outlines, reinforcing that consent process improvements could be made. It also illustrates the value of PAC visits in patient education, as shown by higher levels of recall when compared to DOS.

Multi-level spine endoscopy: A review of available evidence and case report.

In the last ten years, there has been an exponential increase in endoscopic spinal surgery practice.With improvements in equipment quality and the availability of high definition camera systems, cervical endoscopic disc resection is now a viable alternative to anterior cervical decompression and fusion (ACDF) or disc arthroplasty for the treatment of disc prolapse and low grade stenosis.Based on the current literature, there is now strong evidence to support the use of transforaminal endoscopic approaches for the treatment of thoracic disc prolapse.There is now level I evidence to show that outcomes following transforaminal endoscopic discectomy (TED) are at least equivalent to those after open microdiscectomy, with an expected shorter operating time, lesser requirement for analgesia, reduced duration of post-operative disability, more rapid rehabilitation and lower costs of care. However, it should be recognised that there is a significant learning curve for TED.New endoscopic techniques with interlaminar approaches allow the decompression of central and lateral recess stenosis. Future developments will facilitate vision and access to the spine with 3D imaging and robotics at the forefront.We present a case report of whole spine endoscopic decompression to illustrate the potential of endoscopic surgery at all spinal levels. Cite this article: EFORT Open Rev 2017;2:317-323. DOI: 10.1302/2058-5241.2.160087.

Medium-term patient-reported outcomes after total hip replacement for displaced hip fractures.

INTRODUCTION: The aim of the present study was to define the medium-term outcomes following total hip replacement (THR) for hip fracture. METHODS: We prospectively followed up 92 patients who underwent THR for a displaced hip fracture over a 3-year period between 2007 and 2010. These patients were followed up at 5 years using the Oxford Hip Score, Short-Form 12 (SF-12) questionnaire and satisfaction questionnaire. These outcomes were compared to the short-term outcomes previously reported at 2 years to determine any significant differences. RESULTS: Mean follow-up was at 5.4 years with a mean age at follow-up of 76.5 years. Seventy-four patients (80%) responded. Patients reported excellent functional outcomes and satisfaction (mean Oxford Hip Score 40.3; SF-12 Physical Health Composite Score 44.0; SF-12 Mental Health Composite Score 46.2; mean satisfaction 90%). The rates of dislocation (2%), deep infection (2%) and revision (3%) were comparable to those quoted for elective THR. When compared with 2-year follow-up, there were no statistically significant adverse changes in outcome parameters. CONCLUSIONS: Medium-term outcomes for THR after hip fracture in fit older patients are excellent, and these results demonstrate that the early proven benefits of this surgery are sustained into the midterm.

Open Finger Fractures: Incidence, Patterns of Injury and the Influence of Social Deprivation.

BACKGROUND: This study investigates the patterns and epidemiology of open finger fractures. There is little good data about these injuries. METHODS: Data were collected prospectively in a single trauma unit serving a well-defined population. RESULTS: Over a 15 year period 1090 open finger fractures were treated in 1014 patients. These made up the vast majority of open fractures treated in the trauma unit during this period. The incidence of open finger fractures was 14.0 per 100,000 patients per year. Deprivation did not influence the incidence of open finger fractures but did affect treatment choices for women. Most open finger fractures resulted from crush injuries or falls and required only simple operative treatments: debridement, lavage and early mobilization. CONCLUSIONS: Open finger fractures formed the majority of the workload of open fractures at our trauma centre but usually required simple treatments only. Social deprivation was not shown to influence the patterns or epidemiology of these injuries but did affect treatment choices for women.

Cerebrospinal fluid markers of neuroinflammation in delirium: a role for interleukin-1ß in delirium after hip fracture.

OBJECTIVE: Exaggerated central nervous system (CNS) inflammatory responses to peripheral stressors may be implicated in delirium. This study hypothesised that the IL-1ß family is involved in delirium, predicting increased levels of interleukin-1ß (IL-1ß) and decreased IL-1 receptor antagonist (IL-1ra) in the cerebrospinal fluid (CSF) of elderly patients with acute hip fracture. We also hypothesised that Glial Fibrillary Acidic Protein (GFAP) and interferon-γ (IFN-γ) would be increased, and insulin-like growth factor 1 (IGF-1) would be decreased. METHODS: Participants with acute hip fracture aged >60 (N=43) were assessed for delirium before and 3-4 days after surgery. CSF samples were taken at induction of spinal anaesthesia. Enzyme-linked immunosorbent assays (ELISA) were used for protein concentrations. RESULTS: Prevalent delirium was diagnosed in eight patients and incident delirium in 17 patients. CSF IL-1ß was higher in patients with incident delirium compared to never delirium (incident delirium 1.74 pg/ml (1.02-1.74) vs. prevalent 0.84 pg/ml (0.49-1.57) vs. never 0.66 pg/ml (0-1.02), Kruskal-Wallis p=0.03). CSF:serum IL-1ß ratios were higher in delirious than non-delirious patients. CSF IL-1ra was higher in prevalent delirium compared to incident delirium (prevalent delirium 70.75 pg/ml (65.63-73.01) vs. incident 31.06 pg/ml (28.12-35.15) vs. never 33.98 pg/ml (28.71-43.28), Kruskal-Wallis p=0.04). GFAP was not increased in delirium. IFN-γ and IGF-1 were below the detection limit in CSF. CONCLUSION: This study provides novel evidence of CNS inflammation involving the IL-1ß family in delirium and suggests a rise in CSF IL-1ß early in delirium pathogenesis. Future larger CSF studies should examine the role of CNS inflammation in delirium and its sequelae.

Preventing venous thromboembolism in elective upper limb surgery.

BACKGROUND: Deep venous thrombosis (DVT) and pulmonary embolism (PE) have considerable clinical and economic consequences. The prevention of venous thrombosis and PE are increasingly seen as quality markers for surgery. Guidance is available from a number of sources to stratify risk for different patients and procedures and to define an appropriate standard of care. Despite this, best practice is unclear. METHODS: We reviewed the available guidance for orthopedic surgeons undertaking elective upper limb surgery with respect to prescribing DVT prophylaxis. Material was identified from publications produced by professional and regulatory bodies, including United States Surgeon General, United Kingdom Department of Health, the American Academy of Orthopaedic Surgeons, the Scottish Intercollegiate Guideline Network, the National Institute for Clinical Excellence, and the American College of Chest Physicians, as well as a structured MEDLINE database search. RESULTS: The picture is particularly confused in the case of elective upper limb surgery. Much of the evidence for prescribing DVT prophylaxis is related to lower limb surgery or trauma surgery. CONCLUSIONS: Failing to prescribe prophylaxis against venous thromboembolism (VTE) may be presented as a failure of care. We present a review of current guidance and the supporting evidence in order to establish evidence-based best practice and a standard of care for elective upper limb surgery. LEVEL OF EVIDENCE: Review Article.

Total hip replacement in patients with hip fracture: a matched cohort study.

BACKGROUND: There is increasing interest in the use of total hip replacement (THR) for reconstruction in patients who have displaced intracapsular hip fractures. Patient selection is important for good outcomes, but criteria have only recently been clearly defined in the form of national guidelines. This study aimed to investigate patient reported outcomes and satisfaction after THR undertaken for displaced hip fractures and to compare these with a matched cohort of patients undergoing contemporaneous THR for osteoarthritis to assess the safety and effectiveness of national clinical guidelines. METHODS: One hundred patients were selected for treatment of displaced hip fractures using THR between January 1, 2007, and December 31, 2009. These patients were selected using national guidelines and were matched for age and sex with 300 patients who underwent contemporaneous THR as an elective procedure for osteoarthritis. RESULTS: Patients undergoing THR for both fracture and as an elective procedure reported excellent outcomes and satisfaction. Patients with hip fracture had better postoperative Oxford hip scores (p < 0.001) and SF-12 physical component scores (p < 0.001). Mental component scores were poorer for patients with hip fracture (p < 0.001). In this series, the rates of major complications for patients with hip fracture were higher than for elective patients. For patients with hip fracture, the rate of dislocation was 2%, the rate of deep infection was 3%, and early revision operation was required for 2% of patients. The 30-day mortality for patients with hip fracture was zero. Nevertheless, these complication rates are similar to those widely reported in the literature and considered within acceptable limits after elective operation. CONCLUSION: For selected patients, THR undertaken for displaced fractures of the hip produces outcomes that are at least equivalent to those achieved after elective operation. Selection is critical to this success, and the extended use of current guidelines is appropriate and safe. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Hemiarthroplasty augmented with bone graft for the failed hallux metatarsophalangeal Silastic® implant.

Symptomatic failure of Silastic® implants at the hallux metatarsophalangeal joint can result in the challenging problem of instability which may be painful. There is often marked bone loss making reconstruction difficult. Arthrodesis sacrifices joint movement while excision arthroplasty shortens the ray and is less acceptable to active patients. We describe a case in which reconstruction was achieved by using a porous coated metatarsophalangeal hemiarthroplasty augmented with bone graft with good early results. This previously unreported technique may offer an additional surgical option for reconstruction, maintaining joint movement without compromising future arthrodesis or excision arthroplasty as salvage measures. Long term follow up is required to confirm the success of this technique.

Patient-reported outcomes after simple dislocation of the elbow.

BACKGROUND: The current study was designed to investigate the epidemiology and long-term clinical and patient-reported outcomes following simple dislocation of the elbow in adults. METHODS: We identified all adult patients treated at our trauma center for a simple dislocation of the elbow during a ten-year period. One hundred and forty patients were eligible for review, and 110 (79%) were reviewed at a mean of eighty-eight months (range, sixteen to 171 months) after the injury. This review included clinical examination, the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, the Oxford elbow questionnaire, and a patient satisfaction questionnaire. RESULTS: Patients reported long-term residual deficits in the range of elbow motion. The mean DASH score was 6.7 points (95% confidence interval, 4 to 9 points). The mean Oxford elbow score was 90.3 points (95% confidence interval, 87.8 to 92.9 points). The mean satisfaction score was 85.6 points (95% confidence interval, 82.2 to 89 points). Sixty-two patients (56%) reported residual subjective stiffness of the elbow. Nine patients (8%) reported subjective instability, and sixty-eight (62%) reported residual pain. The satisfaction and DASH scores showed good correlation with absolute range of motion in the injured elbow, as did the overall Oxford elbow score and the pain and function components of that score. Multivariate analysis demonstrated that loss of elbow flexion (p = 0.001) and female sex (p = 0.002) were both independent predictors of a poorer DASH score. Reduced elbow flexion also predicted a poorer score on the function component of the Oxford elbow score (p = 0.02). A reduced flexion-extension arc of motion predicted a poorer overall Oxford elbow score (p = 0.02), a poorer score on the pain component of the Oxford elbow score (p = 0.02), and poorer overall satisfaction (p = 0.005). Female sex predicted a poorer score on the psychosocial component of the Oxford elbow score (p < 0.05). CONCLUSIONS: Although patients generally report a favorable long-term functional outcome after simple dislocation of the elbow, these injuries are not entirely benign. The rate of residual pain and elbow stiffness is high. Functional instability is less common and does not often limit activities.

A retrospective study of risk factors for poor outcomes in methicillin-resistant Staphylococcus aureus (MRSA) infection in surgical patients.

BACKGROUND: Since its isolation, Methicillin-resistant Staphlococcus aureus (MRSA) has become a major cause of hospital acquired infection (HAI), adverse patient outcome and overall resource utilisation. It is endemic in Scotland and widespread in Western hospitals. MRSA has been the subject of widespread media interest--a manifestation of concerns about sterile surgical techniques and hospital cleanliness. This study aimed to investigate patient outcome of MRSA infections over the last decade at a major orthopaedic trauma centre. The objective was to establish the association of variables, such as patient age and inpatient residence, against patient outcome, in order to quantify significant relationships; facilitating the evaluation of management strategies with an aim to improving patient outcomes and targeting high-risk procedures. METHODS: This is a retrospective study of the rates and outcomes of MRSA infection in orthopaedic trauma at the Royal Infirmary of Edinburgh. Data was collated using SPSS 14.0 for Windows(R). Shapiro-Wilkes testing was performed to investigate the normality of continuous data sets (e.g: age). Data was analysed using both Chi-Squared and Fisher's exact tests (in cases of expected values under 5) RESULTS: This study found significant associations between adverse patient outcome (persistent deep infection, osteomyelitis, the necessity for revision surgery, amputation and mortality) and the following patient variables: Length of inpatient stay, immuno-compromise, pre-admission residence in an institutional setting (such as a residential nursing home) and the number of antibiotics used in patient care. Despite 63% of all infections sampled resulting from proximal femoral fractures, no association between patient outcome and site of infection or diagnosis was found. Somewhat surprisingly, the relationship between age and outcome of infection was not proved to be significant, contradicting previous studies suggesting a statistical association. Antibiotic prophylaxis, previously identified as a factor in reducing overall incidence of MRSA infection, was not found to be significantly associated with outcome. CONCLUSIONS: Early identification of high-risk patients as identified by this study could lead to more judicious use of therapeutic antibiotics and reductions in adverse outcome, as well as socioeconomic cost. These results could assist in more accurate risk stratification based on evidence based evaluation of the significance of the risk factors investigated.

Cerebrospinal fluid cortisol levels are higher in patients with delirium versus controls.

BACKGROUND: High plasma cortisol levels can cause acute cognitive and neuropsychiatric dysfunction, and have been linked with delirium. CSF cortisol levels more closely reflect brain exposure to cortisol, but there are no studies of CSF cortisol levels in delirium. In this pilot study we acquired CSF specimens at the onset of spinal anaesthesia in patients undergoing hip fracture surgery, and compared CSF and plasma cortisol levels in delirium cases versus controls. FINDINGS: Delirium assessments were performed the evening before or on the morning of operation with a standard battery comprising cognitive tests, mental status assessments and the Confusion Assessment Method. CSF and plasma samples were obtained at the onset of the operation and cortisol levels measured. Twenty patients (15 female, 5 male) aged 62 - 93 years were studied. Seven patients were diagnosed with delirium. The mean ages of cases (81.4 (SD 7.2)) and controls (80.5 (SD 8.7)) were not significantly different (p = 0.88). The median (interquartile range) CSF cortisol levels were significantly higher in cases (63.9 (40.4-102.1) nmol/L) than controls (31.4 (21.7-43.3) nmol/L; Mann-Whitney U, p = 0.029). The median (interquartile range) of plasma cortisol was also significantly higher in cases (968.8 (886.2-1394.4) nmol/L, than controls (809.4 (544.0-986.4) nmol/L; Mann Whitney U, p = 0.036). CONCLUSIONS: These findings support an association between higher CSF cortisol levels and delirium. This extends previous findings linking higher plasma cortisol and delirium, and suggests that more definitive studies of the relationship between cortisol levels and delirium are now required.

3-amino-7-phthalazinylbenzoisoxazoles as a novel class of potent, selective, and orally available inhibitors of p38alpha mitogen-activated protein kinase.

The p38 mitogen-activated protein kinase (MAPK) is a central signaling molecule in many proinflammatory pathways, regulating the cellular response to a multitude of external stimuli including heat, ultraviolet radiation, osmotic shock, and a variety of cytokines especially interleukin-1beta and tumor necrosis factor alpha. Thus, inhibitors of this enzyme are postulated to have significant therapeutic potential for the treatment of rheumatoid arthritis, inflammatory bowel disease, osteoporosis, and many other diseases where aberrant cytokine signaling is the driver of disease. Herein, we describe a novel class of 3-amino-7-phthalazinylbenzoisoxazole-based inhibitors. With relatively low molecular weight, these compounds are highly potent in enzyme and cell-based assays, with minimal protein shift in 50% human whole blood. Compound 3c was efficacious (ED 50 = 0.05 mg/kg) in the rat collagen induced arthritis (CIA) model.