Comparison of acute outcomes from elective total hip replacements and after fragility femoral neck fractures in nonagenarians.

BACKGROUND: Hip hemiarthroplasty has traditionally been used to treat displaced femoral neck fractures in older, frailer patients whilst total hip replacements (THR) have been reserved for younger and fitter patients. However, not all elderly patients are frail, and some may be able to tolerate and benefit from an acute THR. Nonagenarians are a particularly heterogenous subpopulation of the elderly, with varying degrees of independence. Since THRs are performed electively as a routine treatment for osteoarthritis in the elderly, its safety is well established in the older patient. The aim of this study was to compare the safety of emergency THR to elective THR in nonagenarians. METHODS: A retrospective 10-year cohort study was conducted using data submitted to the National Hip Fracture Database (NHFD) across three hospitals in one large NHS Trust. Data was collected from 126 nonagenarians who underwent THRs between 1st January 2010 - 31st December 2020 and was categorised into emergency THR and elective THR groups. Mortality rates were compared between the two groups. Secondary outcomes were also compared including postoperative complications (dislocations, revision surgeries, and periprosthetic fracture), length of stay in hospital, and discharge destination. RESULTS: There was no significant difference in mortality between the two groups, with 1-year mortality rates of 11.4% and 12.1% reported for emergency and elective patients respectively (p = 0.848). There were no significant differences in postoperative complication rate and discharge destination. Patients who had emergency THR spent 5.56 days longer in hospital compared to elective patients (p = 0.015). CONCLUSION: There is no increased risk of 1-year mortality in emergency THR compared to elective THR, in a nonagenarian population. Therefore, nonagenarians presenting with a hip fracture who would have been considered for a THR if presenting on an elective basis should not be precluded from an emergency THR on safety grounds. TRIAL REGISTRATION: Not necessary as this was deemed not to be clinical research, and was considered to be a service evaluation.

Minimally invasive sacroiliac fusion, a case series, and a literature review.

INTRODUCTION: Non-autoimmune sacroiliac joint pain contributes to nearly a quarter of low back pain patients. Non-surgical management fails to satisfy patients. A new minimally invasive technique for sacroiliac stabilization has been introduced, defying the traditional rules of fusion. The results outside explanatory trials and in day-to-day practice have not been reported. MATERIALS AND METHODS: This case series includes 20 patients diagnosed with chronic sacroiliac pain resistant to conservative management for at least 6 months. The diagnosis was confirmed with a positive sacroiliac injection. Patients underwent stabilization using the iFuse® implant. Patients were followed up for a minimum of one year. The primary outcome was the functional outcomes, assessed using VAS, ODI, and SF36. Secondary procedure rates, complication rates, and radiological assessments of fusion were collected as secondary outcomes. RESULTS: At one year, the mean VAS score improved from 81.25 ± 10.7 SD preoperatively to 52.5 ± 26.8, p-value 0.0013. The mean ODI improved from 54.8 ± 11.21 SD preoperatively to 41.315 ± 15.34, P value = 0.0079. The mean PCS and MCS of SF36 improved by 17 and 20 points, respectively. Only 55% of patients achieved the MCID for the VAS score. 35% of the cohort had secondary procedures. DISCUSSION: Minimally invasive sacroiliac fusion resulted in an improvement in mean functional scores with a wide dispersion. Patients not achieving MCID are patients with either a malpositioned implant, an associated lumbar pathology, or an inaccurate diagnosis. Our results are underwhelming compared to similar work but are still better than conservative cohorts in comparative studies. CONCLUSION: Minimally invasive sacroiliac fusion can be used successfully in select patients. Attention to diagnosis and surgical technique can improve the reproducibility of results.

External validation study of hip peri-prosthetic joint infection with cemented custom-made articulating spacer (CUMARS).

INTRODUCTION: Peri-prosthetic joint infection (PJI) is a devastating complication after total hip arthroplasty (THA). The use of custom-made articulating spacers (CUMARS) has been described for use in the first of 2-stage treatment. We report our outcomes of managing PJI using CUMARS. METHODS: Patients undergoing 1st-stage revision using the Exeter standard stem, all-polyethylene acetabulum and antibiotic-loaded cement were identified. Medical records were assessed for demographics, microbiological and operative treatment, complications, eradication of infection and reoperations. No postoperative restrictions were enforced. 2nd-stage revision was undertaken in the presence of pain or subsidence. RESULTS: 53 patients underwent 1st-stage revision using this technique. The average follow-up was 3.9 (range 0.5-7.2) years. Infection was eradicated in 47 (88.7%) patients. 2 patients had chronic infection managed with suppressive antibiotics, 2 patients died before eradication confirmed, 1 patient had raised inflammatory markers but no positive aspiration cultures, 1 patient was lost to follow-up. Complications occurred in 5 (9.4%) patients - 4 dislocations and 1 infected haematoma. 4 patients required a repeated 1st stage. 2nd-stage revision was performed in 19 patients (35%). CONCLUSIONS: The CUMARS technique is an effective way of eradicating PJI after THA. It maintains function by providing a stable construct that permits weight-bearing. It delays or negates the need for 2nd-stage revision. Furthermore, it allows surgeons to choose between managing patients prospectively as a single-stage revision with the option of reverting to a 2nd stage.

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.

Minimally Invasive Sacroiliac Joint Fusion with Triangular Titanium Implants: Cost-Utility Analysis from NHS Perspective.

OBJECTIVE: The aim was to identify the cost-effectiveness of minimally invasive sacroiliac joint fusion (MI SIJF) surgery with titanium triangular implants for patients with sacroiliac joint (SIJ) pain who have failed conservative management, compared to non-surgical management (NSM) from a National Health Service (NHS) England perspective. METHODS: Over a time horizon of 5 years, a cohort state transition model compared the costs and outcomes of treating patients with MI SIJF to those of traditional NSM treatment pathways. The NSM arm included two treatments: grouped physical therapy and corticosteroid injections (PTSI) or radiofrequency ablation (RFA). Three different strategies were considered: (1) a stepped pathway, (2) patients split between PTSI and RFA, and (3) RFA only. The outcome measure was incremental cost-effectiveness ratio (ICER), reported in 2018 British pounds per quality-adjusted life year (QALY) gained. One-way and probabilistic sensitivity analyses were used to test the robustness of the model results. RESULTS: Patients undergoing MI SIJF accrued total procedure-related and pain-management costs of £8358, while NSM treatment strategy 1 had total costs of £6880. The MI SIJF cohort had 2.98 QALYs compared to strategy 1 with 2.30 QALYs. This resulted in an ICER for MI SIJF versus strategy 1 of £2164/QALY gained. Strategy 2 of the NSM arm had lower costs than strategy 1 (£6564) and 2.26 QALYs, and this resulted in an ICER of £2468/QALY gained for MI SIJF. Strategy 3 of the NSM arm had lower costs than strategy 1 (£6580), and this resulted in 2.28 QALYs and an ICER of £2518/QALY gained for MI SIJF. Probabilistic sensitivity analysis shows that at a threshold of £20,000/QALY gained, MI SIJF has a probability of being cost-effective versus NSM strategies of 96%, 97%, and 91% for strategies 1, 2, and 3, respectively. CONCLUSION: MI SIJF appears to be cost-effective over a 5-year time horizon when compared to traditional NSM pathways in an NHS context.

Results of hydroxyapatite ceramic coated primary femoral stem in revision total hip replacement.

PURPOSE: The purpose of this study was to assess survival rate, functional and radiological outcomes when using a hydroxyapatite-ceramic fully coated primary femoral stem in revision total hip arthroplasty. METHODS: Patients who underwent revision total hip arthroplasty using the Furlong hydroxyapatite-ceramic (HAC)-coated (Joint Replacement Instrumentation Ltd., Sheffield, UK) primary stem were retrospectively identified between 2013 and 2017. A total of 30 hips in 27 patients were identified and the mean follow-up duration was 44 months. Post-operative radiographs were scrutinized for signs of component loosening by two independent assessors. Patient's functional outcomes were assessed using the Oxford hip score and compared pre- and post-operatively. The prevalence of thigh pain was assessed at the latest follow-up. RESULTS: The most common cause of revision was adverse reactions to metal debris (ARMD) (46.6%). The overall complication rate was 13.3%. Results at final follow-up demonstrated 100% survival rate and no reported incidence of thigh pain. Using paired t test, all patients had a statistically significant (P < 0.05) improvement in post-operative mean Oxford hip score of 35 compared to a mean pre-operative score of 14. Radiographic analysis of the latest follow-up radiographs revealed no signs of component loosening or component subsidence. CONCLUSION: With a 100% survival rate and excellent reported functional outcomes, we believe that our experience and results support the use of primary cementless stems in selected revision cases.

Thompson Hemiarthroplasty for Femoral Neck Fracture Is Associated With Increased Risk of Dislocation.

BACKGROUND: This contemporaneous large multicenter retrospective study reflective of current practice, assesses the impact of patient factors, prosthesis selection, and implant features on the risk of dislocation after hip hemiarthroplasty for femoral neck fracture. METHODS: Radiographic records for 4116 consecutive patients who underwent a hip hemiarthroplasty between January 1, 2009 and September 30, 2017 at 3 acute hospitals (including a regional major trauma center) for a neck of femur fracture were reviewed in conjunction with United Kingdom National Hip Fracture Database records. RESULTS: In total, 4116 patients were eligible for inclusion in the study; 63 of 4116 (1.5%) dislocations were identified. Patient age, gender, preoperative abbreviated mental test score, postoperative abbreviated mental test score, and American Society of Anaesthesiologists grade were not found to be significant predictors of dislocation rates (P < .05). The Furlong prosthesis was the most commonly used implant (2280/4116, 55.4%) followed by the Exeter V40 + Unitrax head (1179/4116, 28.6%), other implants used during the study period were the monoblock Austin-Moore and Thompson implants. Hemiarthroplasty operations undertaken with the Thompson (24/273, 3.7%) were found to have significantly higher dislocation rates (P < .05). Cemented vs uncemented, variable vs fixed offset, and monoblock vs modular implant designs did not contribute to higher dislocation rates (P < .05). Surgeon seniority was also not a significant risk factor for subsequent dislocation (P < .05). CONCLUSIONS: Thompson hip hemiarthroplasties are associated with higher dislocation rates when compared to a contemporaneous cohort of implant choices and considerations for their use should be made in conjunction with this major risk factor for the need for subsequent operations.

Techniques for the Management of Failed Surgery for Fractures of the Neck of Femur.

BACKGROUND: The majority of modern surgical treatments for managing hip fracture in the elderly are successful and result in a very low rate of revision surgery. Subsequent operations are however occasionally necessary. Optimal management of complications such as infection, dislocation or failed fixation is critical in ensuring that this frail patient group is able to survive their treatment and return to near normal function. METHODS: This paper is a discussion of techniques, tips and tricks from a high volume hip fracture unit. CONCLUSION: This article is a technique-based guide to approaching the surgical management of failed hip fracture treatment and includes sections on revising both failed fixation and failed arthroplasty.

Changing trends in the management of intertrochanteric hip fractures - A single centre experience.

With an annual incidence greater than 65,000 in the United Kingdom, hip fractures are a common but debilitating injury predominantly affecting those over 65. Treatment is based on the anatomical location of the fracture relative to the capsule of the hip joint - fractures occurring within it are treated by arthroplasty, while extracapsular fractures are an indication for fixation. Intertrochanteric fractures are further grouped as stable (AO/OTA 31A1/A2) or unstable (31A3) which in turn governs in the current UK guidelines whether this fixation is achieved with a dynamic hip screw or intramedullary device. Anecdotally, some units are tending towards intramedullary devices for 31A2 fractures as well, a practice which from the evidence does not appear to confer benefit and carries an excess cost. We reviewed our data submitted to the National Hip Fracture Database over the last five years and identified all intertrochanteric fractures, from which cohort we identified all patients with 31A2 fractures by review of radiographs. The cohort comprised 370 patients. We then recorded age, gender, ASA grade, abbreviated mental test score, residence from where admitted, length of stay, destination on discharge and whether any further operations were required. There was no significant difference in the demographics of the groups, year-on-year, except gender mix. There was a significant, twenty-fold rise in the use of intramedullary devices between 2011 and 2015. Length of stay, length of overall episode of care, revision rates, mortality and destination on discharge were unchanged. This use is not supported by NICE guidelines and this study offers no evidence to contradict this position. We advocate all centres examine their practice to avoid a costly intervention without clinical benefit.

Oligodeoxynucleotide inhibition of Toll-like receptors 3, 7, 8, and 9 suppresses cytokine production in a human rheumatoid arthritis model.

Toll-like receptors (TLRs) are innate immune receptors that respond to both exogenous and endogenous stimuli and are suggested to contribute to the perpetuation of chronic inflammation associated with rheumatoid arthritis (RA). In particular, the endosomal TLRs 3, 7, 8, and 9 have more recently been postulated to be of importance in RA pathogenesis. In this study, pan inhibition of the endosomal TLRs by a phosphorothioate-modified inhibitory oligodeoxynucleotide (ODN) is demonstrated in primary human B cells, macrophages, and RA fibroblasts. Inhibition of TLR8 was of particular interest as TLR8 has been associated with RA pathogenesis in both human and murine arthritis models. ODN1411 competitively inhibited TLR8 signaling and was observed to directly bind to a purified TLR8 ectodomain, suggesting inhibition was through a direct interaction with the receptor. Addition of ODN1411 to human RA synovial membrane cultures significantly inhibited spontaneous cytokine production from these cultures, suggesting a potential role for one or more of the endosomal TLRs in inflammatory cytokine production in RA and the potential for inhibitory ODNs as novel therapies.

A comparison of reproductive parameters of female Amur tigers (Panthera tigris altaica) in the wild and captivity.

A healthy population of captive Amur tigers might assist recovery of the wild population in Northeast China if individuals were properly prepared and considered suitable for release in the wild. We analyzed the breeding records of 68 female Amur tigers from 1995 to 2010 in the Hengdaohezi Felid Breeding Center of China and compared the reproductive parameters of this population to wild female Amur tigers. We found that the reproductive parameters of the captive population (the age of first parturition, length of gestation and litter survival rate) were not significantly different from those of wild Amur tigers. Differences in birth date and litter size between wild and captive populations may be caused by management protocols for the captive population or insufficient field data from the wild population. Reproductive parameters of females giving birth after losing a litter were similar to parameters of females that did not lose a litter, except for birth date. These results provide no indication of major problems in using captive females for a breeding program for release of cubs into the wild, but additional information is still needed to assess their suitability.

Effectiveness of femur bone indexes to segregate wild from captive minks, Mustela vison, and forensic implications for small mammals.

Utilization of free-living populations of endangered wildlife species is usually strictly prohibited or restricted. Farming of endangered species can provide products that are in demand as a countermeasure. A novel forensic issue arises because it becomes necessary to discriminate the origin of given wildlife products. We tested the effectiveness of five measurements and four indexes of femur bone using farmed minks (n = 40) and escapees (n = 32). Results showed all measurements, namely body mass (L(f)), body length (M(f)), femur mass (V(f)), femur length (M(b)), and femur volume (L(b)), were highly discriminatory. However, they are susceptible to the influence of nutrition level and sex. Femur length index (I(fl)), femur linear density (D(l)), and femur volume density (D(v)) eliminated the influence of level of nutrition and were highly effective. However, I(fl) and D(l) were influenced by sex (p = 0.000). Because D(v) was not influenced by sex (p = 0.683) and was highly effective, it was the preferred index.

Consenting operative orthopaedic trauma patients: challenges and solutions.

Guidelines exist to obtain informed consent before any operative procedure. We completed an audit cycle starting with retrospective review of 50 orthopaedic trauma procedures (Phase 1 over three months to determine the quality of consenting documentation). The results were conveyed and adequate training of the staff was arranged according to guidelines from BOA, DoH, and GMC. Compliance in filling consent forms was then prospectively assessed on 50 consecutive trauma surgeries over further three months (Phase 2). Use of abbreviations was significantly reduced (P = 0.03) in Phase 2 (none) compared to 10 (20%) in Phase 1 with odds ratio of 0.04. Initially, allocation of patient's copy was dispensed in three (6% in Phase 1) cases compared to 100% in Phase 2, when appropriate. Senior doctors (registrars or consultant) filled most consent forms. However, 7 (14%) consent forms in Phase 1 and eleven (22%) in Phase 2 were signed by Core Surgical Trainees year 2, which reflects the difference in seniority amongst junior doctors. The requirement for blood transfusion was addressed in 40% of cases where relevant and 100% cases in Phase 2. Consenting patients for trauma surgery improved in Phase 2. Regular audit is essential to maintain expected national standards.

Perioperative management of elderly patients suffering a hip fracture.

Preparing elderly patients for emergency hip fracture surgery is a significant challenge for hospital staff. This article discusses the principles of preoperative care in these patients, and the rationale for such strategies, based on evidence and current guidelines. Such guidance increasingly reflects a national standard of care.

The results of total hip arthroplasty for fractured neck of femur in octogenarians.

The role of total hip arthroplasty (THA) for fracture in octogenarians remains unclear. Over a two-year period, 354 patients aged > 80 years were admitted with a displaced intracapsular hip fracture. Using defined clinical guidelines, 38 patients underwent THA with a median age of 84 years, mean follow-up of 20 months. Primary outcomes were dislocation, 30-day and one-year mortality, revision surgery and periprosthetic fracture. There were no dislocations or periprosthetic fractures and patient survival was 97% at 30 days and 87% at one year. There was one revision for deep infection. This study demonstrates that THA for selected octogenarians can be performed safely, allows the majority of patients to return to independent living and has a low complication rate.

Methane emissions and production potentials of forest swamp wetlands in the Eastern Great Xing'an Mountains, Northeast China.

Measurements of methane flux at a few inundated sites in China have been extrapolated to obtain estimates on a national scale. To enable those national estimates to be refined and to compare flux from geographically separated sites comprising the same wetland types, we used a closed chamber method to measure methane flux in uninundated Betula platyphylla-and Larix gmelinii-dominated peatlands in the Northeast China. Our measurements were taken from both vegetated and bare soil surfaces, and we compared flux with environmental measures including vegetation biomass, soil temperature and soil characteristics. We found that methane flux was low, and that there were no significant differences between wetland types, indicating that environmental influences were dominant. We found that flux was positively correlated to temperature in the surface layers of the soil, the above-ground biomass of the shrub and herb layers, total soil carbon and total soil nitrogen; and we suggest that emissions may be due to anaerobic microcosms in the surface layers. The methane production potentials of the soils were low and similar between both sites but inconsistent with the differences between fluxes, and inconsistent with production potentials and fluxes reported from the same wetland types elsewhere, indicating that there were subtle environmental differences between wetlands classed as being of the same type. Differences between fluxes in vegetated chambers with bare soil chambers were insignificant, indicating that no methane emission through aerenchyma occurred at our sites. We concluded that wetland type was not an accurate predictor of methane flux.

Ovine nematodes in wild lagomorphs in Australia and first record of Trichostrongylus rugatus in free living lagomorphs.

Gastrointestinal parasites are a major problem for sheep graziers and anthelmintic resistance has been reported worldwide. Given that in experimental circumstances, sheep helminths are able to develop in rabbits and hares, and that hares are very mobile and sympatric with sheep in many regions of Australia, free-living lagomorphs were investigated regarding carriage of ovine nematode parasites under field conditions. We performed specific worm counts in the gastrointestinal tracts of 88 rabbits and 110 hares. We revealed that ruminant worms are common in hares (prevalence 79%) and that they are occasionally found in rabbits (9%). Statistical analyses showed that the ruminant worm Trichostrongylus colubriformis occurred frequently in hares whilst rabbits were commonly infected with lagomorph-specific Trichostrongylus retortaeformis. Detection of the ovine worm Trichostrongylus rugatus is reported for the first time in wild lagomorphs. The potential for cross-transmission between hares and sheep in the natural environment is much more prevalent than previously believed.

Is the large size of the pinna of the ear of the European hare (Lepus europaeus) due to its role in thermoregulation or in anterior capital shock absorption?

Large pinnae are characteristic of the Leporids, and the pinna is known to have a thermoregulatory role. Another role has been hypothesized for the pinna of Lepus spp., as a part of a suspensory system for the greater portion of the head, absorbing shock that might otherwise interfere with vision during high-speed locomotion. We compared the lengths of the pinnae of adult European hares Lepus europaeus from the source population in the cooler climate of England with those of the introduced population in the warmer climate of Australia, and we compared the lengths of the pinnae of hares that had grown in cooler weather with those that had grown in warmer weather. There were no significant differences between each of the comparisons, indicating that the size of the pinna is not determined by thermoregulatory requirements at rest. We compared the growth in length of the pinnae and the legs with growth in body mass, and growth in the mass of the pinnae with the masses of the head and the eyeballs, and found support for the suspension hypothesis. We suggest that the rapid growth of the pinna is because visual acuity is a function of absolute eye size, not relative eye size, yet juvenile hares are subject to the same predator pressure as adult hares, and equally need to maximize visual acuity while running at high speeds in dim light. We believe that the large size of the pinna is determined by its role in anterior capital suspension, not in thermoregulation.

The experimental establishment of ruminant nematodes in European hares (Lepus europaeus).

The factors that control the demography of European hare Lepus europaeus populations are poorly understood, but it has been recognized that the decline of hares in Europe is associated with an increasing intensity of agricultural activity. Many mechanisms have been suggested. We propose another mechanism; a negative impact arising from ingestion of the infective larvae of ruminant livestock. We dosed juvenile hares from a worm-free colony with a conservative dose from a mixed culture of infective larvae of the nematode parasites of sheep and cattle. We examined the hares post-mortem for the establishment of those ruminant nematodes, differences in weight changes, and the shedding of eggs. We found that under the circumstances of our trial, Trichostrongylus colubriformis and to a lesser extent T. rugatus, T. vitrinus, and Teladorsagia circumcincta were able to establish as adults in the dosed animals. We found strongyle eggs in the faeces of the dosed hares, and were able to culture larvae from those eggs. However, the ecological significance of our findings, if any, remains to be elucidated. Because of their mobility, hares may transmit resistant strains of parasites between grazing properties.