Is it safe to restart elective day-case surgery? Lessons learned from upper limb ambulatory trauma during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic has impacted on the provision of elective and trauma orthopaedic surgery worldwide with millions of operations cancelled. The risk of patients developing COVID-19 after undergoing ambulatory procedures in hospitals is unknown. This paper aims to investigate the risk of developing COVID-19 from day-case and overnight stay upper limb procedures during the peak of the pandemic in London, and to discuss the implications for the safe management of elective hand and upper limb patients in the coming months. METHODS: 56 patients underwent emergency trauma upper limb procedures as a day case or with a single overnight stay from 1st March to May 31, 2020 at two central London hospitals that were also key players in the pan-London COVID response. Data was collected retrospectively from clinical and theatre records. Patients were contacted post-operatively and answered a structured questionnaire, including whether patients had experienced any of the symptoms suggestive of COVID-19 in the 14 days prior or 30 days following surgery. RESULTS: Of 56 patients, one patient reported COVID-19 symptoms, which were minor and did not require hospitalisation. Five patients experienced minor post-operative complications such as stiffness and scar hypersensitivity; one patient had a superficial wound infection. The mean age was 46 years (20-90) with 68% patients ASA I, 25% ASA II and 4% ASA III. 9% had LA, 30% a regional block and 61% had a GA. The most common operation was a distal radius open reduction and internal fixation. The average time spent in hospital was 11 h (3-34 h) and 12 patients required an overnight stay. The median length of face-to-face follow up was 38.5 days. CONCLUSION: Our study suggests that, with appropriate precautions, elective upper limb ambulatory surgery can be safely restarted with a low risk of contracting COVID-19 or its complications.

Pelvic injury is not just pelvic fracture.

Pelvic trauma is complex, most of current work centres around pelvic haemorrhage and fractures. It is important to remember that there is more anatomy in the pelvis than bones and vessels. A 29-year-old male patient was admitted after an Road Traffic Collision (RTC) where his motorbike T-boned a car. He was noted to have a traumatic dislocation of his right testicle, which spontaneously reduced in the emergency department and he was admitted for scrotal exploration and observation. Due to difficulty in mobilising postoperatively, he underwent an MRI, which showed diastasis of his pubis symphysis as well as left-sided adductor tendon rupture, not evident on his initial CT scan, and underwent pelvic fixation. Why should an emergency physician be aware of this? This case emphasises the alternate differentials with pelvic trauma in a haemodynamically stable patient, and the requirement for continuous reassessment in patients failing to improve.

Lateral epicondylitis: the condition and current management strategies.

Lateral epicondylitis or tennis elbow is a common condition estimated to affect between 1 and 3% of adults. As a result of its high prevalence, both primary and secondary care physicians are frequently presented with this problem, so knowledge of its presentation and up-to-date management strategies is essential. This review collates the most recent evidence on lateral epicondylitis to help the clinician perform assessments and make treatment decisions, based on the best current clinical practice.

Non-operative management of an isolated lateral collateral ligament injury in an adolescent patient and review of the literature.

We present a rare case of isolated traumatic pure ligamentous rupture of the lateral collateral ligament of the knee in an adolescent high-level footballer managed non-operatively with a good functional outcome and return to sport in 4 months.

Current practice of BHS members in the treatment of osteonecrosis of the femoral head in adults.

INTRODUCTION: The management of osteonecrosis (ON) of the femoral head remains controversial. It is unclear the extent to which non-arthroplasty procedures are used and there has been no previous report of the trends in operative management of ON in the UK. Our objective is to report current trends in management of ON of the femoral head amongst specialist hip surgeons in the UK. METHODS: A single-stage internet-based survey was e-mailed to 352 eligible members of the British Hip Society (BHS). This consisted of 10 question stems including 16 hypothetical clinical scenarios with imaging. RESULTS: 115 active Consultant members of the BHS completed the survey. For symptomatic pre-collapse ON we found core decompression (CD) was the most common operative intervention and for post-collapse ON we found that total hip arthroplasty (THA) was the most common operative intervention. We found no difference in the rate of operative intervention between 24 and 48-year-old patients at any stage of ON but joint preserving procedures were more often selected for the younger patient and arthroplasty for the older patient. Surgeons were more likely to offer arthroplasty to a 48-year-old patient at an earlier stage of disease. CONCLUSIONS: Our respondents would offer different operative interventions dependent on stage of ON and patient age. Core decompression (CD) and arthroplasty were common but variation in treatment options offered suggests a lack of consensus amongst UK hip surgeons. We suggest that further research such as a prospective RCT is needed to gain consensus on management of this condition.

Outcomes for Elderly Patients With Atypical Femoral Fractures Compared to Typical Femoral Fractures for Length of Stay, Discharge Destination, and 30-Day Mortality Rate.

INTRODUCTION: Despite increasing recognition of atypical femoral fractures (AFFs), there's conflicting evidence about incidence, aetiology, and short-term outcomes of these injuries. This study reports the incidence of AFFs at our center and compares the early postoperative outcomes against typical femoral fractures (TFFs). METHODS: A retrospective observational cohort study of patients presenting to our trauma unit between November 2015 and July 2016 was undertaken. Inclusion criteria required radiologically confirmed proximal femoral fracture, which was then categorized as AFF or TFF. Primary outcome measures included length of stay, discharge destination, and 30-day mortality. RESULTS: Two hundred thirty-nine patients presented to our trauma unit over 9 months with either a fractured neck of femur or proximal femoral fracture. A total of 122 were identified as pertrochanteric, subtrochanteric, or proximal femoral shaft fractures of which 25 (20.5%) displayed atypical radiographic features consistent with AFF. The 2 groups were similar for average age (TFF 85.3 years vs AFF 85.0 years), gender (19% vs 16% male gender), American Society of Anaesthesiology grade (3.0 vs 3.0), cognitive score (abbreviated mental test score = 7.03 vs 7.08), and preinjury place of residence (88.9% vs 92.0% lived in own home). Typical fractures were fixed with either dynamic hip screw or intramedullary nailing, all atypical fractures were fixed with intramedullary nailing. There was no statistical difference between the 2 groups for length of stay (12.8 days vs 14.3 days; P > .05), discharge to preinjury residence (45.1% vs 36%; P > .05), or 30-day mortality (8.1% vs 12%; P > .05). DISCUSSION: In our predominantly geriatric population atypical radiographic features were observed in around 10% of patients presenting with proximal femoral fractures or fractured neck of femur. Previous studies have reported poor outcomes for pain, mobility, and length of stay after AFF. However, we observed no difference in short-term outcome measures when compared to patients with typical proximal femoral fracture patterns at our trauma unit. CONCLUSION: With modern principles of trauma care outcomes achieved following AFFs may be equivalent to typical femoral fractures in the geriatric population.

Hip Fractures in Centenarians: Has Care Improved in the National Hip Fracture Database Era?

INTRODUCTION: The number of centenarians in the United Kingdom is increasing. An associated increase in the incidence of hip fractures in the extreme elderly population is expected. The National Hip Fracture Database (NHFD) initiative was introduced in 2007 aiming to improve hip fracture care. There is a paucity of literature on the outcomes of centenarians with hip fractures since its introduction. The aim of this study is to report our experience of hip fractures in centenarians in the era since the introduction of the NHFD to assess outcomes in terms of mortality, time to surgery, length of stay, and complications. METHODS: A retrospective case note study of all centenarians managed for a hip fracture over a 7-year period at a London district general hospital. RESULTS: We report on 22 centenarians sustaining 23 hip fractures between 2008 and 2015. Twenty-one fractures were managed operatively. For patients managed operatively, in-hospital, 30-day, 3-month, 6-month, 1-year, 2-year, 3-year, and 5-year cumulative mortalities were 30%, 30%, 39%, 50%, 77%, 86%, 95%, and 100%, respectively. In-hospital mortality was 100% for those managed nonoperatively. Mean time to surgery was 1.6 days (range: 0.7-6.3 days). Mean length of stay on the acute orthopedic ward was 23 days (range: 2-51 days). Seventy-one percent had a postoperative complication most commonly a hospital-acquired pneumonia or urinary tract infection. CONCLUSION: Compared to a series of centenarians with hip fractures prior to the introduction of the NHFD, we report a reduced time to surgery. Mortality and hospital length of stay were similar.

Computer navigation of the acetabular component in total hip arthroplasty: a narrative review.

Total hip arthroplasty (THA) is a common procedure for primary osteoarthritis, but increasing numbers are also being performed for other pathologies such as secondary arthritis, inflammatory arthropathies and trauma. Estimates suggest that around 8.5 million people in the UK are affected by joint pain secondary to arthritis and a rising ageing population has resulted in an increase in THA operations of around 4% per year over the last six years.Multiple studies have shown that THA provides improved quality of life scores, but there remains the burden of complications which account for 15% of £1bn NHS liability payouts. DaPalma et al analysed the financial impact of complications following THA and found the additional cost of a dislocation within six weeks of surgery is 342% of the primary cost.Following primary THA, complications may occur as a result of incorrect component positioning of the femoral stem, the acetabular cup or both. It is known that acetabular malposition may lead to increased rates of dislocation, impingement, edge-loading, polyethylene wear, pelvic osteolysis and prosthesis failure.Acetabular component positioning has been described as the single most important factor in dictating risk of dislocation following THA. Furthermore, instability and dislocation after primary THA is the most common single reason for revision surgery accounting for 22.5% of all revisions and 33% of acetabular revisions.We outline the currently available methods of acetabular navigation comparing freehand techniques with computer and robotic-assisted navigation of the acetabular component. Cite this article: Davenport D, Kavarthapu V. Computer navigation of the acetabular component in total hip arthroplasty: a narrative review. EFORT Open Rev 2016;1:279-285. DOI: 10.1302/2058-5241.1.000050.

The 30-year wait for treatment of an acutely painful knee.

A 63-year-old retired man presented to our clinic reporting a severely painful, localised knee pain present for around 30 years and associated with a spontaneous palpable lump. He was prompted to seek medical advice at this point because his symptoms were exacerbated when his young grandchildren bumped into the knee. While radiographs were unhelpful, ultrasonography revealed a well-defined, subcutaneous soft tissue mass at the anterior aspect of the knee. Surgical excision was performed as a day case. Histological examination of the mass showed a glomus tumour. This patient had suffered for many years as a result of this painful mass but full resolution of his pain occurred immediately after excision.

Stromal cell-derived factor-1 and hepatocyte growth factor guide axon projections to the extraocular muscles.

Vertebrate eye movements depend on the co-ordinated function of six extraocular muscles that are innervated by the oculomotor, trochlear, and abducens nerves. Here, we show that the diffusible factors, stromal cell-derived factor-1 (SDF-1) and hepatocyte growth factor (HGF), guide the development of these axon projections. SDF-1 is expressed in the mesenchyme around the oculomotor nerve exit point, and oculomotor axons fail to exit the neuroepithelium in mice mutant for the SDF-1 receptor CXCR4. Both SDF-1 and HGF are expressed in or around the ventral and dorsal oblique muscles, which are distal targets for the oculomotor and trochlear nerves, respectively, as well as in the muscles which are later targets for oculomotor axon branches. We find that in vitro SDF-1 and HGF promote the growth of oculomotor and trochlear axons, whereas SDF-1 also chemoattracts oculomotor axons. Oculomotor neurons show increased branching in the presence of SDF-1 and HGF singly or together. HGF promotes the growth of trochlear axons more than that of oculomotor axons. Taken together, these data point to a role for both SDF-1 and HGF in extraocular nerve projections and indicate that SDF-1 functions specifically in the development of the oculomotor nerve, including oculomotor axon branch formation to secondary muscle targets. HGF shows some specificity in preferentially enhancing development of the trochlear nerve.

Human CHN1 mutations hyperactivate alpha2-chimaerin and cause Duane's retraction syndrome.

Duane's retraction syndrome (DRS) is a complex congenital eye movement disorder caused by aberrant innervation of the extraocular muscles by axons of brainstem motor neurons. Studying families with a variant form of the disorder (DURS2-DRS), we have identified causative heterozygous missense mutations in CHN1, a gene on chromosome 2q31 that encodes alpha2-chimaerin, a Rac guanosine triphosphatase-activating protein (RacGAP) signaling protein previously implicated in the pathfinding of corticospinal axons in mice. We found that these are gain-of-function mutations that increase alpha2-chimaerin RacGAP activity in vitro. Several of the mutations appeared to enhance alpha2-chimaerin translocation to the cell membrane or enhance its ability to self-associate. Expression of mutant alpha2-chimaerin constructs in chick embryos resulted in failure of oculomotor axons to innervate their target extraocular muscles. We conclude that alpha2-chimaerin has a critical developmental function in ocular motor axon pathfinding.