Birmingham hip resurfacing: a systematic review of outcomes at minimum 10-years follow-up.

Although controversy surrounding the use of metal-on-metal (MoM) arthroplasty implants continues to exist, satisfactory clinical and radiological outcomes have been reported following Birmingham Hip Resurfacing (BHR) at long-term follow-up, leading to an Orthopaedic Data Evaluation Panel (ODEP) rating of 13A. The purpose of this study was to systematically review the literature to evaluate the functional outcomes, radiological outcomes and revision rates following BHR at a minimum of 10 years follow-up. Using the PRISMA guidelines, two independent reviewers performed a literature search using Pubmed, Embase and Scopus databases. Only studies reporting on outcomes of BHR with a minimum of 10 years' follow-up were considered for inclusion. A total of 12 studies including 7132 hips (64.8% males), with mean follow-up of 11.5 years (10-15.3), met our inclusion criteria. Of included patients, 94.3% of patient underwent BHR for osteoarthritis at a mean age was 52.0 years (48-52). At final follow-up, 96% of patients reported being satisfied with their BHR, with mean Harris Hip Scores of 93.6 and Oxford Hip Scores of 16.5. Rates of radiological femoral neck narrowing of greater than 10% and non-progressive radiological loosening were reported as 2.0% and 3.8% respectively. At final follow-up, the overall revision rate was 4.9% (334/7132), deep infection rate was 0.4%, metal allergy/insensitivity rate was 1.6%, metal reaction rate was 0.3%, rate of peri-prosthetic fracture was 0.9% and aseptic loosening rates were 1.6%. This systematic review demonstrates that BHR results in satisfactory clinical outcomes, acceptable implant survivorship, low complication rates and modest surgical revision rates in the long-term at minimum 10-year follow-up.

Fat Embolism Syndrome - A Qualitative Review of its Incidence, Presentation, Pathogenesis and Management.

Fat Embolism Syndrome (FES) is a poorly defined clinical phenomenon which has been attributed to fat emboli entering the circulation. It is common, and its clinical presentation may be either subtle or dramatic and life threatening. This is a review of the history, causes, pathophysiology, presentation, diagnosis and management of FES. FES mostly occurs secondary to orthopaedic trauma; it is less frequently associated with other traumatic and atraumatic conditions. There is no single test for diagnosing FES. Diagnosis of FES is often missed due to its subclinical presentation and/or confounding injuries in more severely injured patients. FES is most frequently diagnosed using the Gurd and Wilson criteria, like its rivals it is not clinically validated. Although FES is a multi-system condition, its effects in the lung, brain, cardiovascular system and skin cause most morbidity. FES is mostly a self-limiting condition and treatment is supportive in nature. Many treatments have been trialled, most notably corticosteroids and heparin, however no validated treatment has been established.

Phase III, randomized trial of mirvetuximab soravtansine versus chemotherapy in patients with platinum-resistant ovarian cancer: primary analysis of FORWARD I.

BACKGROUND: Mirvetuximab soravtansine (MIRV) is an antibody-drug conjugate comprising a folate receptor alpha (FRα)-binding antibody, cleavable linker, and the maytansinoid DM4, a potent tubulin-targeting agent. The randomized, open-label, phase III study FORWARD I compared MIRV and investigator's choice chemotherapy in patients with platinum-resistant epithelial ovarian cancer (EOC). PATIENTS AND METHODS: Eligible patients with 1-3 prior lines of therapy and whose tumors were positive for FRα expression were randomly assigned, in a 2 : 1 ratio, to receive MIRV (6 mg/kg, adjusted ideal body weight) or chemotherapy (paclitaxel, pegylated liposomal doxorubicin, or topotecan). The primary endpoint was progression-free survival [PFS, Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1, blinded independent central review] in the intention-to-treat (ITT) population and in the prespecified FRα high population. RESULTS: A total of 366 patients were randomized; 243 received MIRV and 109 received chemotherapy. The primary endpoint, PFS, did not reach statistical significance in either the ITT [hazard ratio (HR), 0.98, P = 0.897] or the FRα high population (HR, 0.69, P = 0.049). Superior outcomes for MIRV over chemotherapy were observed in all secondary endpoints in the FRα high population including improved objective response rate (24% versus 10%), CA-125 responses (53% versus 25%), and patient-reported outcomes (27% versus 13%). Fewer treatment-related grade 3 or higher adverse events (25.1% versus 44.0%), and fewer events leading to dose reduction (19.8% versus 30.3%) and treatment discontinuation (4.5% versus 8.3%) were seen with MIRV compared with chemotherapy. CONCLUSIONS: In patients with platinum-resistant EOC, MIRV did not result in a significant improvement in PFS compared with chemotherapy. Secondary endpoints consistently favored MIRV, particularly in patients with high FRα expression. MIRV showed a differentiated and more manageable safety profile than chemotherapy.

A growing challenge: The rise of femoral periprosthetic fractures - An 11-year observational study.

INTRODUCTION: The demand for joint arthroplasty has risen as our elderly population increases and ages. With this so to has the number of patients suffering periprosthetic fractures (PPF). The aim of our study was to quantify the burden of PPF and provide an up to date reference of the epidemiology of PPF in Ireland. We also sought to assess length of stay (LOS), resource utilisation and mortality associated with this cohort of patients. METHODS: An eleven-year retrospective observational study was conducted of a consecutive series of patients treated for a femoral PPF. Costs were obtained from activity based tariffs provided by the hospital inpatient enquiry system and mortality was confirmed using the national death events publication system. RESULTS: Over the 11-year study period 174 procedures for a femoral PPF were performed. Mean age of patients was 77.6 years (SD 11.1 years) with 44.7% male. Median ASA grade was 3 (range 1-4) and mean LOS was 19 days. There was a 700% increase in patients undergoing surgery for a PPF over the study period. The mean cost of care was €24,413 in 2017. Thirty-day mortality was 2.9% while one-year mortality was 12.4%. CONCLUSIONS: PPF occur in an elderly comorbid cohort of patients. Care of these patients now makes up a considerable part of the orthopaedic workload and consumes a significant portion of healthcare resources. Patients should be treated in tertiary referral centres with surgeons skilled in their management. Better access to rehabilitation is needed.

Key Service Improvements After the Introduction of an Integrated Orthogeriatric Service.

INTRODUCTION: Models of orthogeriatric care have been shown to improve functional outcomes for patients after hip fractures and can improve compliance with best practice guidelines for hip fracture care. METHODS: We evaluated improvements to key performance indicators in hip fracture care after implementation of a formal orthogeriatric service. Compliance with Irish Hip Fracture standards of care was reviewed, and additional outcomes such as length of stay, access to rehabilitation, and discharge destination were evaluated. RESULTS: Improvements were observed in all of the hip fracture standards of care. Mean length of stay decreased from 19 to 15.5 days (mean difference 3.5 days; P < .05). A higher proportion of patients were admitted to rehabilitation (16.7% vs 7.9%, P < .05), and this happened in a timelier fashion (17.8 vs 24.8 days, P < .05). We found that less patients required convalescence post-hip fracture. DISCUSSION: A standardized approach to integrated post-hip fracture care with orthogeriatrics has improved standards of care for patients. CONCLUSION: Introduction of orthogeriatric services has resulted in meaningful improvements in clinical outcomes for older people with hip fractures.

Assessment of theatre shoe contamination in an orthopaedic theatre.

Prosthetic joint infection (PJI) is a devastating complication of arthroplasty. Numerous protocols reduce potential risk for PJI peri-operatively, but none exist for the management of theatre shoes. Our aim was to assess for bacteria known to cause prosthetic infection on theatre shoes. Forty theatre shoes were analysed; there were coagulase-negative staphylococci on 65% (N = 25), meticillin-susceptible Staphylococcus aureus on 40% (N = 16), and meticillin-resistant S. aureus on 25% (N = 10). Amount of blood spatter correlated poorly with microbial contamination. Shoes harbouring Gram-positive bacteria, including antibiotic-resistant strains, provide a potential route of transmission to the theatre environment.

The Selfie Wrist - Selfie induced trauma.

The selfie phenomenon has exploded worldwide over the past two years. Selfies have been linked to a large number of mortalities and significant morbidity worldwide. However, trauma associated with selfies including fractures, is rarely publicised. Here we present a case series of upper extremity trauma secondary to selfies across all age groups during the summer period. Four cases of distal radius and ulna trauma in all age groups were reported. This case series highlights the dangers associated with taking selfies and the trauma that can result.

Medium term review of the ASR implant system: A single surgeon series.

INTRODUCTION: Both ASR hip resurfacings and stemmed ASR XL arthroplasties have failed at high rates in several published series. We assessed a single surgeon series of these arthroplasties looking to identify factors associated with their failure. METHODS: All surgeries were performed by one surgeon. Patients were evaluated clinically, radiologically and with serial cobalt and chromium ion analysis. RESULTS: 274 implants were analysed - 152 ASR resurfacings and 122 ASR XL implants. Thirty revisions were performed. CONCLUSION: The failure rate of the ASR implant in our series is unacceptably high - its use in routine hip arthroplasty cannot be supported.

Early results of the LPS™ limb preservation system in the management of periprosthetic femoral fractures.

INTRODUCTION: Achieving skeletal fixation in the presence of progressive bone loss is a surgical challenge, especially in cases of periprosthetic fracture (PPF). Unpredictable fracture patterns and preexisting bone loss frequently combine in this patient group. Megaprosthetic arthroplasty allows for immediate mobilisation and shorter periods of rehabilitation. We describe the clinical outcomes of a cohort of LPS™ megaprostheses performed for PPF by a single surgeon at our institution. METHODS: Between July 2013 and November 2015, 23 patients underwent endoprosthetic femoral replacement of which 16 were performed for PPF or bone loss. Patient demographics, surgical indication, operative details, implant composition, blood loss, survival, and revision surgery details were recorded in a prospectively maintained database. Patients underwent serial clinical and X-ray evaluations at 6 weeks, 3 months and 6 months post surgery with yearly reviews thereafter. RESULTS: The PPF cohort consisted of 9 males and 7 females with a mean age of 75 and a mean follow up of 19.2 months. The mean Oxford score prior to fracture was 41 (range 12-48), and 39 (range 13-48, p = 0.6) post megaprosthesis insertion. Postoperative dislocation of the megaprosthesis occurred in two patients (12.5%), with no postoperative infections recorded. CONCLUSION: We report minimal postoperative changes in functional outcome scores. The results of revision arthroplasty with LPS™ proximal femur megaprosthesis were satisfactory in 15/16 patients at a mean follow-up of 19.2 months. We recommend the use of megaprostheses in patients with markedly deficient bone stock for whom other available reconstructive procedures are unavailable.

Traumatic Dorsal Dislocation of the Four Ulnar Metacarpals.

The swollen, painful hand is a familiar sight in the emergency department (ED), and often is seen in the context of alcohol intake, following a fight or in association with multiple trauma, all of which can make accurate assessment challenging. We report a case of complete dorsal dislocation of the four ulnar metacarpals and highlight the importance of early diagnosis and treatment for this unusual injury.

Definitive use of external fixation for pelvic ring injuries (open book/APC2) in pregnancy.

Pelvic fractures in pregnancy are rare, resulting in a paucity of evidence-based management. We describe a case of open book pelvic injury in a 32-year-old woman in her third trimester of pregnancy. She was successfully managed with a supra-acetabular external fixator, which allowed the safe delivery of a healthy baby boy at 34 weeks, via caesarean section. The external fixator was removed postpartum, when the pelvis was deemed stable, and mother and baby both continue to do well. This is the only case in the literature that demonstrates the successful use of external fixation for pelvic injuries in pregnancy.

Increased incidence of femoral fractures in small femurs and women undergoing uncemented total hip arthroplasty - why?

The aim of this study was to investigate the relationship between the geometry of the proximal femur and the incidence of intra-operative fracture during uncemented total hip arthroplasty (THA). We studied the pre-operative CT scans of 100 patients undergoing THA with an uncemented femoral component. We measured the anteroposterior and mediolateral dimensions at the level of division of the femoral neck to calculate the aspect ratio of the femur. Wide variations in the shape of the femur were observed, from round, to very narrow elliptic. The femurs of women were narrower than those of men (p < 0.0001) and small femurs were also narrower than large ones. Patients with an intra-operative fracture of the calcar had smaller and narrower femurs than those without a fracture (p < 0.05) and the implanted Corail stems were smaller in those with a fracture (mean size 9 vs 12, p < 0.0001). The variability of the shape of the femoral neck at the level of division contributes to the understanding of the causation of intra-operative fractures in uncemented THA.

A comparative analysis of the occupational energy expenditure of radiologists versus clinicians.

BACKGROUND: Sedentary lifestyles have been associated with increased morbidity and mortality. Radiology as a profession may be sedentary compared to some clinical disciplines. AIM: Our aim was to measure the occupation-related energy expenditure of a cohort of radiologists versus clinicians using a specialized pedometer. METHODS: 25 radiologists and 25 clinicians (15 surgeons, 8 physicians and 2 emergency physicians) were measured. The amount of steps walked, stairs climbed and calories burned on a given day from 9 a.m. to 5 p.m. were compared between the groups. RESULTS: The difference in mean calorie usage per day was 320 greater, and steps walked per day 2,985 greater, in clinicians than in radiologists (p < 0.0001 for each). CONCLUSION: Such a difference in calorie intake can have significant long-term health implications in terms of increased weight or BMI. Means of combating this deficit are discussed.

John Thomas sign--a memorable but misleading sign in hip fractures.

OBJECTIVE: The John Thomas sign is a favourite of medical students and theorizes that in femoral neck fractures, the male member will lie to the side of the fracture on the plain radiograph. The aim of this study was to evaluate the accuracy, and examine the phenomenon of eponymous signs. We sought to answer the following questions: (1) How accurate is the sign in the context of a consecutive series of male patients with hip fractures? (2) Is there a relationship between side and size of penile lie and the side of fracture? HYPOTHESIS: That the accuracy of the John Thomas sign is, like many eponymous signs, spurious. MATERIALS AND METHODS: Two hundred male AP pelvis radiographs were examined, of which 100 had a hip fracture and compared these against 100 control films that did not. Age at presentation, and the side, length and angle of penile lie were measured. RESULTS: The results show two findings: that the accuracy of the supposed "sign" is less accurate than the toss of a coin; and that left lie and left-sided fractures are more common. We fail to show a relationship between side of fracture, John Thomas size or degree of angulation. CONCLUSION: John Thomas sign is no better than the toss of a coin in relation to hip fractures, and is not related to side of fracture, or penile attitude. We propose that the side of lie observed in male fractures may be as a result of handedness or natural underlying body asymmetry rather than as a result of the fracture. LEVEL OF EVIDENCE: Level III Case control study.

Glutamine preconditioning protects against local and systemic injury induced by orthopaedic surgery.

INTRODUCTION: Long bone surgery represents a significant surgical insults, and may cause severe local and systemic sequalae following both planned and emergent surgery. Glutamine offers pharmacological modulation of injury through clinically acceptable preconditioning. This effect has not been previously demonstrated in an orthopaedic model. AIMS: The aim of the study was to test the hypothesis that glutamine preconditioning protects against the local and systemic effects of long bone trauma in a rodent model. METHODS: Thirty two adult male Sprague-Dawley rats were randomised into four groups: Control group which received trauma without preconditioning; Normal Saline preconditioning 1 hour before trauma; Glutamine preconditioning 1 hour before trauma; Glutamine preconditioning 24 hours prior to trauma. Trauma consisted of bilateral femoral fracture following intramedullary instrumentation. Blood samples were taken before the insult, and at an interval four hours following this. Bronchioalveolar lavage (BAL) was performed, with skeletal muscle and lung harvested for evaluation. RESULTS: Glutamine pre-treated rats had lower Creatine Kinase levels, less creatinine elevation, and a significant reduction in neutrophil infiltration into BAL fluid. Glutamine pre-treated rats showed less muscle and lung oedema. This effect was more pronounced for the group which received glutamine 24 hours before trauma. CONCLUSION: Preconditioning with a single bolus of intravenous glutamine prior to planned orthopaedic intervention affords loco-regional and distal organ protection. We believe these finding have significant implications for elective orthopaedic surgery where significant soft tissue and long bone manipulation is anticipated.

Breast carcinoma with brain metastases: clinical analysis and immunoprofile on tissue microarrays.

BACKGROUND: Development of brain metastasis in patients with breast carcinoma correlates with poor outcome. Identification of tumor characteristics associated with breast cancer brain metastases (BCBM) could help identify patients at risk. PATIENTS AND METHODS: We studied 209 patients with BCBM. We evaluated a panel of proteins relevant to the biology of breast carcinoma on tissue microarrays of 133 primary tumors and 56 BCBM, including paired samples from 43 patients, and correlated the findings with the clinical outcome. RESULTS: The median survival after BCBM diagnosis was 19 months (95% confidence interval, 13-23 months). Patients presenting with solitary metastasis had a significantly longer median survival than those with multiple lesions (25 versus 11 months, P ≤ 0.0001). We found no significant discordance in the expression of tested markers, but identified a possible association between the expression of basal cytokeratin CK5/6 in the primary carcinoma and the development of multiple rather than solitary brain metastases. CONCLUSIONS: Expression of antigens commonly associated with breast carcinoma does not differ significantly between the primary tumor and the corresponding brain metastases. Although no specific immunoprofile identifies breast carcinomas that develop brain metastases, we observed a possible association between CK5/6 expression in the primary tumor and multiple versus solitary BCBM.

A five-year review of publication productivity among Irish orthopaedic units.

BACKGROUND: The academic productivity of trainees, consultants and institutions is frequently judged by the quantity of articles published in peer-reviewed medical journals. AIM: To assess the publication history of Irish orthopaedic units over a 5-year period, and to identify patterns of publication. METHODS: A PubMed search was performed of each consultant affiliated with each orthopaedic unit in the country for between 2004 and 2008. Publications were classified by individual, institution, publication type and impact factor. RESULTS: Over the 5 years of the study, 239 papers were published from 19 orthopaedic units, in 69 different journals. Fifty-six consultants had at least one senior author publication, with seven consultants having more than ten. Impact factors of the journals targeted varied considerably and reveals an interesting duality among authors when opting for profile or prestige. CONCLUSION: We feel this study represents a comprehensive and novel review of the state of publishing in a surgical specialty.

Recent onset neck pain with associated neurological deficit--Pott's disease remains an important differential diagnosis.

The incidence of spinal tuberculosis is increasing in developed nations. In Ireland, half of all cases seen in the most recent decade for which figures are available were diagnosed in 2005-2007, the three most recent years for which there is complete data. We discuss a patient who presented with neurological complications due to destructive spinal tuberculous disease affecting the sixth cervical vertebra.