Predicting 30-day mortality after hip fracture: the G4A calibrated prognostic tool.

INTRODUCTION: Proximal femoral fracture is common with a high mortality (7% mortality at 30 days). Accurate determination of mortality risk allows better consenting, clinical management and expectation management. Our study aim was to develop a prognostic tool to predict 30-day mortality after proximal femoral fracture, among patients treated within a dedicated hip fracture unit. MATERIALS AND METHODS: We collected data from our hospital concerning 2210 patients with 2287 proximal femoral fractures. The clinical parameters of 97 patients who died within 30 days of surgery were analysed. We used logistic regression to determine if the parameters' relationship with 30-day mortality was statistically significant or not. The statistically significant parameters were used to create a prognostic model for predicting 30-day mortality. RESULTS: The 5 independent predictors of 30-day mortality were gender, age, admission source, preoperative Abbreviated Mental Test Score (AMTS) and American Society of Anesthesiologists Score (ASA). The highest risk was for males >85 years, admitted from institutional care, with low preoperative mental test score and high ASA grade. Using these predictors, we formulated the G4A score. The Hosmer-Lemeshow 'goodness of fit' test showed good concordance between observed and predicted mortality rates. CONCLUSIONS: We recommend the use of the G4A score to predict 30-day mortality after surgery for proximal femoral fracture, particularly within dedicated hip fracture units. Further research is needed to establish whether the findings of this study are applicable on a national scale.

Upregulation of long non-coding RNA NNT-AS1 promotes osteosarcoma progression by inhibiting the tumor suppressive miR-320a.

OBJECTIVE: To investigate the role and mechanism of action of nicotinamide nucleotide transhydrogenase antisense RNA 1 (NNT-AS1) in osteosarcoma (OS). METHODS: Bioinformatic analysis suggested miR-320a as potential target of NNT-AS1. Influence of NNT-AS1 overexpression or knockdown on OS cell proliferation, colony-formation, apoptosis, migration and invasion capacity was first investigated. Expression levels of NNT-AS1, miR-320a, beta-catenin, RUNX2, IGF-1R, c-Myc, Cyclin D1 and MMP13 were also evaluated by RT-qPCR and western blotting accordingly. Xenograft models using U2OS and OS-732 cells with different NNT-AS1 gene modifications were constructed for tumor formation assay as well as evaluation of miR-320a, beta-catenin and RUNX2 expression in primary lesion. NNT-AS1-overexpressing U2OS cells and NNT-AS1-knockdown OS-732 cells were subject to miR-320a mimic and inhibitor transfection, respectively, to investigate the miR-320a dependency of the osteosarcoma-promoting role of NNT-AS1. RESULTS: NNT-AS1 overexpression significantly increased proliferation, survival and mobility of U2OS cells in vitro as well as its tumor formation ability in vivo, while NNT-AS1 knockdown showed opposite effect on OS-732 cells. In both in vitro and in vivo model, NNT-AS1 expression level significantly correlated with that of beta-catenin, RUNX2, IGF-1R, c-Myc, Cyclin D1 and MMP13 as well as Akt phosphorylation level, and inversely correlated with miR-320a expression. Transfection of miR-320a mimic significantly inhibiter the promoting effect of NNT-AS1 on cell proliferation, survival and mobility of U2OS cells, while miR-320 inhibitor partially rescued that of OS-732 cells. CONCLUSION: NNT-As1 functions as a cancer-promoting lncRNA by downregulating miR-320a, thus increasing the protein expression level of beta-catenin, RUNX2 and IGF-1R as well as activation of Akt in osteosarcoma.

Understanding and interpreting funnel plots for the clinician.

Funnel plots are an increasingly common graphical tool which are widely used in the literature. They were first introduced by Light and Pillemer in 1984 . In scientific literature, funnel plots are used to identify the probability of bias in meta-analyses and compare institutional performance. The ability to identify variation is better with graphical than tabular display. In addition, the way data are presented can directly influence the interpretation of results. This was demonstrated by Marshall et al (2004) , who presented institutional mortality data in both a league table and control chart format. This study illustrated that when displayed as a league table, a greater number of units were identified for investigation than were actually required. The use of control charts or funnel plots may therefore show benefit in reducing the number of inappropriately labelled outliers. This article explains how clinicians should read and interpret funnel plots, and discusses their considerations and limitations.

Elastic stable intramedullary nailing in paediatric forearm fractures: the rate of open reduction and complications.

The aim of this study was to evaluate the rate of open reduction and complications of elastic stable intramedullary nailing (ESIN) in treating unstable diaphyseal forearm fractures in children. We performed a retrospective review of a consecutive series of 102 paediatric patients with a mean age of 9 years (range: 7-14 years) who underwent ESIN of unstable closed forearm fractures at three different centres. Closed reduction of one or both bones was achieved in 68 (67%) patients and open reduction was required in 34 (33%) patients. The rate of open reduction in single-bone fractures (52.2%) was significantly higher than that in both-bone fractures (27.8%) (P=0.04, Fisher's exact test). All the fractures united within 3 months. There were six refractures following nail removal. Five patients had superficial wound infections. Seven patients developed neuropraxia of the sensory branch of the radial nerve. All resolved spontaneously within 3 months of the surgery. ESIN is an effective technique in treating unstable diaphyseal forearm fractures. The need for open reduction should be decided promptly following failed attempts of closed reduction. Single-bone fractures are more likely to require open reduction than both-bone fractures. The radius should be reduced and stabilized first. If open reduction is required, this should be performed through a volar approach rather than a dorsal one.

Blunt chest trauma: bony injury in the thorax.

The management of blunt chest trauma is an evolving concept with no clear current guidelines. This article explores the bony injuries associated with this, focusing on rib fractures and flail segments and the themes around investigation and best management.

Blunt chest trauma: soft tissue injury in the thorax.

The management of blunt chest trauma is evolving. This article discusses the soft tissue injuries associated with blunt chest trauma.

The management of rotator cuff tears in the elderly.

Rotator cuff tears occur commonly in the elderly causing significant pain and disability. In light of new treatment options developed over recent years, this article reviews the diagnosis and operative options available for this condition.

Trigger finger presenting secondary to leiomyoma: a case report.

INTRODUCTION: WE PRESENT A PREVIOUSLY UNDESCRIBED ENTITY: trigger finger secondary to a leiomyoma. This is the first time such a case has been reported and highlights the fact that common conditions can sometimes present secondary to rare diseases. CASE PRESENTATION: A 39-year-old Caucasian man presented with a fairly typical presentation of trigger finger. During surgical treatment, the lesion was excised and sent for histology, which showed tissue consistent with a leiomyoma. The patient made an uneventful recovery. CONCLUSION: Trigger finger is a common condition that is usually easily diagnosed and managed. However, it is important to appreciate that uncommon conditions, such as leiomyoma, can present with what is sometimes considered trivial disease, and one should always consider the differential diagnoses even when faced with relatively benign conditions.

Sealing the acetabular notch: does it improve cement penetration in the acetabulum?

Since the advent of cemented hip replacements inthe 1950s, outcomes of cementing techniques in the stem have improved significantly. These improvements have not translated as readily to the acetabulum. This article suggests further techniques of improving cementiig techniques in the acetabulum.

Detecting patient allergy: beware the LIE.

INTRODUCTION: Allergy detection is important in surgical patients. Historically, the focus has been on drug allergies. There is increasing focus on non-drug allergy, specifically latex, iodine and elastoplast. PATIENTS AND METHODS: The practice and knowledge of 24 pre-registration house officers was evaluated, with regard to patient allergy. For the second phase of the study, the cohort of 367 consecutive patients presenting to the orthopaedic pre-assessment clinic was prospectively assessed. RESULTS: This prospective study demonstrates that standard history-taking misses a large number (38%) of such allergies. CONCLUSIONS: With regard to allergy detection, we are living a LIE (by ignoring latex, iodine, elastoplast allergy). We suggest junior doctors should employ the mnemonic LIED (latex, iodine, elastoplast and drugs) when taking a medical history.

The effects of injection of bovine vaccine into a human digit: a case report.

BACKGROUND: The incidence of needlestick injuries in farmers and veterinary surgeons is significant and the consequences of such an injection can be serious. CASE PRESENTATION: We report accidental injection of bovine vaccine into the base of the little finger. This resulted in increased pressure in the flexor sheath causing signs and symptoms of ischemia. Amputation of the digit was required despite repeated surgical debridement and decompression. CONCLUSION: There have been previous reports of injection of oil-based vaccines into the human hand resulting in granulomatous inflammation or sterile abscess and causing morbidity and tissue loss. Self-injection with veterinary vaccines is an occupational hazard for farmers and veterinary surgeons. Injection of vaccine into a closed compartment such as the human finger can have serious sequelae including loss of the injected digit. These injuries are not to be underestimated. Early debridement and irrigation of the injected area with decompression is likely to give the best outcome. Frequent review is necessary after the first procedure because repeat operations may be required.

Short-listing for orthopaedic specialist registrar posts--what is important?

INTRODUCTION: Competition for specialist registrar (SpR) posts in orthopaedics is high. The aim of the current study was to provide evidence-based advice for applicants applying for SpR posts in orthopaedics. METHODS: The short-listing forms of 273 applicants for orthopaedic SpR posts in South Thames (West) were reviewed. The experience of short-listed candidates was compared with those that were not. RESULTS: We have shown a high chance of being short-listed between 5 and 6 years after qualification with a sharp fall off either side of this. It is clear that a wide range of appropriate experience is more important than high volume and low quality experience in orthopaedics alone. CONCLUSION: Candidates who plan ahead and gain a broad experience have a better chance of progressing in an orthopaedic career. Good, early career advice is essential to achieve this.