The core outcomes for open lower limb fracture study.

Aims: A core outcome set for adult, open lower limb fracture has been established consisting of 'Walking, gait and mobility', 'Being able to return to life roles', 'Pain or discomfort', and 'Quality of life'. This study aims to identify which outcome measurement instruments (OMIs) should be recommended to measure each core outcome. Methods: A systematic review and quality assessment were conducted to identify existing instruments with evidence of good measurement properties in the open lower limb fracture population for each core outcome. Additionally, shortlisting criteria were developed to identify suitable instruments not validated in the target population. Candidate instruments were presented, discussed, and voted on at a consensus meeting of key stakeholders. Results: The Wales Lower Limb Trauma Recovery scale was identified, demonstrating validation evidence in the target population. In addition, ten candidate OMIs met the shortlisting criteria. Six patients, eight healthcare professionals, and 11 research methodologists attended the consensus meeting. Consensus was achieved for the EuroQol five-dimension five-level questionnaire (EQ-5D-5L) and the Lower Extremity Functional Scale (LEFS) to measure 'Quality of life' and 'Walking, gait and mobility' in future research trials, audit, and clinical assessment, respectively. No instrument met consensus criteria to measure 'Being able to return to life roles' and 'Pain or discomfort'. However, the EQ-5D-5L was found to demonstrate good face validity and could also be used pragmatically to measure these two outcomes, accepting limitations in sensitivity. Conclusion: This study recommends the LEFS and EQ-5D-5L to measure the core outcome set for adult open lower limb fracture.

Dual-mobility constructs versus large femoral head bearings in primary and revision total hip arthroplasty: a systematic review and meta-analysis of comparative studies.

BACKGROUND: Both dual-mobility (DM) constructs and large femoral head bearings (⩾36 mm) reduce dislocation following total hip arthroplasty (THA). There is limited research comparing DM with large bearings. METHODS: A systematic review of published literature was performed including studies that compared DM with large femoral head bearings in primary or revision THA according to PRISMA guidelines. The primary outcome was revision surgery for dislocation. The secondary outcome was all-cause revision surgery. Other complications were recorded. 2 authors independently selected studies, performed data extraction, and risk of bias assessment. Treatment effects were assessed using odds ratios and data were pooled using a fixed-effect model, where appropriate. RESULTS: 9 studies, all retrospective, met the final inclusion criteria. 2722 patients received DM and 9,789 large femoral head bearings. The difference in the odds of revision surgery for dislocation (OR 0.67; 95% CI, 0.45-1.01; p = 0.06) and aseptic loosening are unclear (OR 0.61; 95% CI, 0.36-1.05; p = 0.07); including important benefits and no difference. There was a benefit favouring DM for the risk of all-cause revision (OR 0.70; 95% CI, 0.56-0.86; p = 0.001), revision for fracture (OR 0.49; 95% CI, 0.29-0.81; p = 0.005) and dislocation not requiring revision (OR 0.29; 95% CI, 0.14-0.57; p < 0.001). The estimate in the difference in the odds of revision surgery for infection was imprecise (OR 0.78; 95% CI, 05.1-1.20; p = 0.26). CONCLUSIONS: This study provides evidence that there may be clinically relevant benefits of DM constructs over large femoral head bearings. Prospective randomised studies are warranted given these findings.

High incidence of radiolucent lines at the implant-cement interface of a new total knee replacement.

BACKGROUND: Recently introduced total knee arthroplasty (TKA) implants have been linked with the early development of periprosthetic radiolucency (PPRL). The aim of this study was to carry out a retrospective clinical and radiographical analysis of a consecutive series of a new TKA, and to assess the incidence and distribution of PPRL. METHODS: A retrospective review of all new TKA implants performed by a single surgeon at a single hospital between March 2013 and October 2017 was performed. The minimum follow-up period was 3 months, with ongoing patient review at 6, 12 and 36 months. Sequential post-operative radiographs were performed to determine the presence of PPRL. RESULTS: A total of 122 TKAs were identified in 112 patients over the 4.5-year study period. The average follow-up time was 21 months (range 3-51 months). PPRL was noted in 29 TKAs (23.8%). When comparing the PPRL group to those without PPRL, there was a difference in body mass index, with body mass index associated with an increased likelihood of PPRL (P = 0.003). There was no difference in constraint of implant (P = 0.818), cement type (P = 0.340), patella resurfacing (P = 0.286), age (P = 0.984) gender (P = 0.376) or initial mechanical axis deviation (P = 0.054) between groups. PPRL were most commonly seen in tibial anterior-posterior (AP) zone 1 and zone 2 (96.6%), followed by femoral lateral zone 5 (58.6%), tibia lateral zone 1 (55.2%) and tibial lateral zone 2 (53.2%). No patients have required revision surgery. CONCLUSION: A high incidence of early PPRL is seen in patients undergoing primary TKA using a new implant system, mainly involving the tibial component. Ongoing clinical and radiological assessment for patients seems warranted based on these findings.

Physical disruption of intervertebral disc promotes cell clustering and a degenerative phenotype.

To test the hypothesis that physical disruption of an intervertebral disc disturbs cell-matrix binding, leading to cell clustering and increased expression of matrix degrading enzymes that contribute towards degenerative disc cell phenotype. Lumbar disc tissue was removed at surgery from 21 patients with disc herniation, 11 with disc degeneration, and 8 with adolescent scoliosis. 5 µm sections were examined with histology, and 30-µm sections by confocal microscopy. Antibodies were used against integrin α5beta1, matrix metalloproteinases (MMP) 1, MMP-3, caspase 3, and denatured collagen types I and II. Spatial associations were sought between cell clustering and various degenerative features. An additional, 11 non-herniated human discs were used to examine causality: half of each specimen was cultured in a manner that allowed free 'unconstrained' swelling (similar to a herniated disc in vivo), while the other half was cultured within a perspex ring that allowed 'constrained' swelling. Changes were monitored over 36 h using live-cell imaging. 1,9-Di-methyl methylene blue (DMMB) assay for glycosaminoglycan loss was carried out from tissue medium. Partially constrained specimens showed little swelling or cell movement in vitro. In contrast, unconstrained swelling significantly increased matrix distortion, glycosaminoglycan loss, exposure of integrin binding sites, expression of MMPs 1 and 3, and collagen denaturation. In the association studies, herniated disc specimens showed changes that resembled unconstrained swelling in vitro. In addition, they exhibited increased cell clustering, apoptosis, MMP expression, and collagen denaturation compared to 'control' discs. Results support our hypothesis. Further confirmation will require longitudinal animal experiments.

The effect of patient, fracture and surgery on outcomes of high energy neck of femur fractures in patients aged 15-50.

INTRODUCTION:: High-energy femoral neck fractures in young patients can be devastating, with the risk of osteonecrosis, nonunion, malunion and lifelong morbidity. The aim of this study is to define the effects of patient, fracture and surgical factors on the outcome of high-energy femoral neck fractures in patients aged from 15 to 50 years. METHODS:: A retrospective review was conducted of high-energy femoral neck fractures in patients aged 15-50 managed surgically at a Level 1 Trauma Centre, using a prospectively recorded trauma database. Low energy trauma (including falls from <1 m), medical conditions adversely affecting bone density, and pathological fractures were excluded. A clinical and radiological review was performed. The primary outcome measures were the development of osteonecrosis or nonunion leading to total hip arthroplasty (THA). Secondary outcome measures included osteotomy or other surgical procedures, quality of reduction and malunion. RESULTS:: 32 patients meeting the inclusion criteria were identified between January 2008 and July 2015. The mean follow-up was 58.5 months (range 980-3,048 days). 3 patients (9.4%) required THA. No other surgical procedures were performed. None of the 29 other patients developed radiologically apparent osteonecrosis. Fracture type, displacement, anatomical reduction and fixation type were not statistically significant risk factors affecting these outcomes. For all patients, an average of 8% loss of femoral neck height and 10% femoral neck offset were seen. CONCLUSIONS:: At a mean 4.9-year follow-up, the incidence of high-energy femoral neck fractures leading to THA was 9.4%, as a consequence of osteonecrosis or nonunion. Malunion was common.