A prospective review of Cauda Equina Syndrome referrals received by an on-call orthopaedic department at a major trauma unit.

INTRODUCTION: Cauda Equina Syndrome (CES) is one of the genuine orthopaedic emergencies. Diagnosis of acute CES is challenging and may be missed, resulting in considerable medicolegal claims. In Ireland, nearly €21 million in compensation has been paid out over a 10-year period due to the diagnosis being missed. As a result, defensive practices have resulted in an increased number of referrals for CES to the on-call orthopaedic service in a major trauma unit. METHODS: A prospective data-capturing exercise was carried out of all referrals for acute CES to the orthopaedic on-call department in a tertiary-level university-affiliated teaching hospital between August and November 2023. Qualitative data was captured including referral source, referring clinician grade, in-hours or out-of-hours referral, MRI on referral, red flags as identified by the referring team, red flags as identified by the orthopaedic team, and outcome. RESULTS: Forty referrals for CES were made over the duration of this audit. Seventeen (42.5%) referrals were made in-hours, and 23 (57.5%) were referred out-of-hours. Only five (12.5%) of these referrals had an MRI done at the time of the referral. No patients were transferred for an out-of-hours MRI to another hospital. Only five (12.5%) patients required surgical decompression-none of these patients required an out-of-hours emergent decompression. CONCLUSION: There is a lack of understanding as to what exactly is being referred-resulting in a referral volume which is over ten times the expected number of CES cases being made to our unit. The lack of out-of-hours MRI access poses a significant concern for patient outcomes.

Rationalising pre-operative trauma bloods can lead to significant cost savings.

BACKGROUND: A full set of pre-operative bloods is being done on nearly all trauma patients who are admitted to our institute for surgery-regardless of variables such as patient age, injury sustained, or co-morbidities. This leads to unnecessary bloods being taken. AIMS: The primary aims are (1) to calculate the costs associated with routine pre-operative bloods and (2) to examine how much money could be saved by retrospectively applying a more pragmatic pre-operative bloods policy. METHODS: Trauma theatre cases over a 5-week period were identified with their pre-operative bloods and post-operative transfusions. Labour, material, and processing costs were estimated for each test. An updated pre-operative blood schedule was proposed and applied retrospectively to see if cost savings could be found. RESULTS: Of the 173 orthopaedic procedures performed, 109 (63%) had a group and screen or crossmatch pre-operatively. Fifteen (8.6%) required a post-operative blood transfusion. One hundred and twenty-eight (74%) patients had a full blood count, and renal profile taken pre-operatively. A full set of bloods costs approximately €51.23 to take and process. When the updated pre-operative blood guidelines were retrospectively applied, it would have led to cost savings of €2496 over the 5-week period of this audit, and if extrapolated up to 1 year, could lead to potential annual savings of €25,960. CONCLUSIONS: We have demonstrated that an excessive amount of unnecessary pre-operative bloods have been taken using the current blood schedule. A pragmatic pre-operative blood schedule can lead to significant actual cost savings.

High rate of tibial debonding and failure in a popular knee replacement : a follow-up review.

AIMS: Total knee arthroplasty (TKA) is a common and safe orthopaedic procedure. Zimmer Biomet's NexGen is the second most popular brand of implant used in the UK. The primary cause of revision after the first year is aseptic loosening. We present our experience of using this implant, with significant concerns around its performance with regards early aseptic loosening of the tibial component. METHODS: A retrospective, single-surgeon review was carried out of all of the NexGen Legacy Posterior Stabilized (LPS) TKAs performed in this institute. The specific model used for the index procedures was the NexGen Complete Knee System (Legacy Knee-Posterior Stabilized LPS-Flex Articular Surface, LPS-Flex Femoral Component Option, and Stemmed Nonaugmentable Tibial Component Option). RESULTS: Between 2013 and 2016, 352 NexGen TKAs were carried out on 331 patients. A total of 62 TKAs have been revised to date, giving an all-cause revision rate of 17.6% at a minimum of five years. Three of these revisions were due to infection. Overall, 59 of the revisions were performed for aseptic loosening (16.7%) of the tibial component. The tibial component was removed intraoperatively without instrumentation due to significant tibial debonding between the implant-cement interface. CONCLUSION: While overall, we believe that early aseptic loosening is multi-factorial in nature, the significantly high aseptic revision rate, as seen by an experienced fellowship-trained arthroplasty surgeon, has led us to believe that there is a fundamental issue with this NexGen implant design. Continued implant surveillance and rigorous review across all regions using this particular implant is warranted based on the concerning findings described here. Cite this article: Bone Jt Open 2022;3(6):495-501.

Repair of sternoclavicular joint ligament: a novel approach.

BACKGROUND: Posterior sternoclavicular dislocations are common in younger patients and are frequently due to high energy sporting incidents. AIM: We aim to demonstrate a novel technique that is safe and aims to provide good functional post-operative outcomes for patients with this injury. METHODS: This was a single-surgeon case series of four young patients from October 2017 to July 2019. The operative technique involved relocating the joint and holding it in situ with nylon suture tape. The tape was anchored in holes drilled in the sternum and passed through tunnels drilled into the medial clavicle. All of the patients were contacted retrospectively and a Nottingham Clavicle Score (NCS) was performed for each patient on a post-operative basis. RESULTS: No intra-operative or post-operative complications were noted. All of the patients demonstrated a significant improvement in their functional outcomes after the operation. The average NCS for the four patients was 82/100. DISCUSSION: There are a variety of techniques described in the literature to repair this ligament using either plates or tendon grafts. All of these techniques describe the drilling of anteroposterior holes in the manubrium and clavicle which run the intra-operative risk of perforating a major vessel. This paper is the first one to describe a technique which uses superior inferior holes which minimizes the risks, making the procedure safer for the patient. CONCLUSIONS: We believe this novel technique is safer than the existing described techniques, and it does not compromise on functional outcomes.

Hip fracture surgery within 36 hours reduces both 30-day and 1-year mortality rates.

BACKGROUND AND PURPOSE: Currently the Irish Hip Fracture Standards [IHFS] recommend a Time-to-Surgery [TTS] of within 48 h of admission. The aim of our research is to determine if there was a statistically significant relationship between TTS and 30-day or one-year mortality and to assess whether a 48 h window for surgery is still the most appropriate recommendation. METHODS USED: This was a single-hospital retrospective review of all of the fragility hip fractures between 1st January 2013 and 31st December 2017. Patient demographics were described using descriptive statistics. Dependent variables of interest were 30-day mortality and one-year mortality. Independent predictor variables analysed included age, ASA grade, fracture type, surgery performed, anaesthesia administered, length of stay and TTS (hours as an interval variable), TTS in less than 36 h (binary variable) and TTS in less than 48 h (binary variable). When the significant predictor variables were identified, in order to control for confounder variables, a multivariate regression analysis was performed to identify which predictors were still significantly associated with the outcome variables even after controlling for all other known confounder variables. RESULTS: In total, 806 patients were identified. TTS within 36 h was predictive of a significantly lower 30-day mortality when compared to those undergoing surgery after 36 h (p = 0.031). In contrast, TTS within 48 h did not demonstrate a significantly lower 30-day mortality when compared to those undergoing surgery after 48 h (p = 0.104). On multivariate regression analysis, TTS <36 h (p = 0.011) and age (p < 0.0001) were all independently predictive of 30-day mortality. On multivariate regression analysis, both age (p < 0.0001) and TTS < 36 h (p = 0.002) were significantly predictive of one-year mortality. CONCLUSION: Performing hip fracture surgery within 36 h confers a significant reduction in both 30-day and one-year mortality rates when compared to patients undergoing surgery outside of this time frame. A 36-h window also appears to be superior to a 48-h window because performing surgery within 48 h has no significant impact on the reduction of 30-day mortality rates. We recommend that national guidelines reflect these important findings.

Assessing outcomes in hip fracture patients under the age of 60.

BACKGROUND: Hip fractures are a common and serious orthopaedic injury. The principle of treatment for hip fractures in the "non-elderly" patient is to preserve the native hip. There is limited published literature in this area. AIM: The aim of this research is to review all of the "non-elderly" hip fracture patients to report on the demographics, fracture patterns, fixation types, and revisions. METHODS: This was a retrospective single-site review of all of the "non-elderly" patients who underwent operative management for hip fractures between 1999 and 2019. A manual review was done of all of the x-rays for the identified patients to confirm the fracture type and identify further surgeries. RESULTS: Three hundred and eighty-one patients were identified. The average age was 48.4 years old. Two hundred and thirty nine of them were intra-capsular, and 142 of them were extra-capsular fractures. Dynamic hip screw (DHS) was the most popular fixation method. In the recent decade of data, the number of hemi-arthroplasties remained consistent, but the number of total hip arthroplasties (THAs) performed increased sevenfold. Mean follow-up was 35 months. Forty-three (11%) patients required follow-up surgery. Non-union accounted for 56% of all revisions and avascular necrosis for 19%. THA was performed in 70% of all revisions. CONCLUSION: DHS remains the most widely used fixation technique in an effort to preserve the native hip. The use of THA has increased and surpassed the usage of hemi-arthroplasty in recent times. A high proportion of these patients will go on to develop complications requiring secondary surgery; therefore, they all need long-term follow-up.

Nontraumatic Tibial Polyethylene Insert Cone Fracture in Rotating-Platform Total Knee Arthroplasty.

We report a case of a fracture through the polyethylene (PE) insert cone in a rotating-platform (RP) primary total knee arthroplasty (TKA) implant. This is the first reported case of cone fracture with this particular implant. This case highlights a 65-year-old female presenting with a 4-month history of knee pain and symptoms of instability 10 years after primary RP TKA. At the time of revision surgery, the PE insert cone was found to be fractured 10 mm from the inferior surface of the PE liner. Analysis suggests that the cone fracture occurred by fatigue failure which caused loosening of the tibial tray. Clinicians should be aware that this is a potential cause of failure with an RP TKA in the setting of symptoms including instability and pain.

Polyethylene liner dissociation in a DePuy pinnacle cup with a manufacturer analysis of the failed component.

A 74-year-old patient presented to the emergency department with acute atraumatic hip pain 9 years after her primary left total hip arthroplasty (THA). Plain radiographic imaging demonstrated lateralisation of the femoral head within the acetabular shell-indicating an issue with the polyethylene liner. The patient required revision of the acetabular component and the femoral head, as well as a new polyethylene liner. A detailed analysis of the components removed was performed by DePuy Synthes Engineering. Between 2009 and 2020, 8 publications have documented 52 cases of liner dissociation with the Pinnacle acetabular component and Marathon polyethylene liner. Various theories have been proposed in the literature as all of these components appear to fail in the same way, with shearing of the locking tabs in the polyethylene liner. In spite of a manufacturer analysis of the components, no root cause was identified as to why the polyethylene liner failed.

Perioperative dexamethasone administration reduces 'on-demand' opioid requirements in bilateral total hip arthroplasty.

BACKGROUND: Bilateral joint arthroplasty is currently not common, but its usage is expected to increase in the future. This may result in larger amounts of opioids being consumed by patients due to anticipated increased pain and prolonged recovery from this procedure. AIM: We describe the impact of perioperative steroid administration in a cohort of bilateral total hip arthroplasties (THAs) (44 hips) in relation to post-operative opioid consumption. METHODS: We report a single-surgeon consecutive case series of simultaneously performed bilateral THAs. Nine patients received two doses of 8 mg IV dexamethasone in the perioperative setting. There were 13 patients in the control group that received no dexamethasone. The primary outcome measure was post-operative analgesic requirements (mg/mcg). Secondary outcomes included post-operative pain according to the visual analogue score (VAS), anti-emetic requirements (mg) and length of stay (days). RESULTS: The mean 'on-demand' Oxynorm® (IR oxycodone) usage in the 'steroid' group was lower than the 'non-steroid' group (47 mg vs 111 mg) (p = 0.005). There was also a significant decrease in the mean consumption of pregabalin in the 'steroid' group when compared with the 'non-steroid' group-464 mg versus 570 mg (p = 0.000). There was no reduction in the requirement of 'regularly' prescribed opioid analgesic medications. VAS analysis demonstrated no significant difference between the two groups at any timepoint. The 'steroid' group did have a trend towards a lower total LOS at 4.6 days compared with 5.5 days in the 'non-steroid' group (p = 0.0503). CONCLUSIONS: We recommend the use of perioperative steroids in bilateral THA to reduce the consumption of potentially problematic opioid-based analgesics.

A Correlation of Blood Panel Results and Histologically Confirmed Appendicitis.

Background Appendicitis is the most common indication for emergency surgery in the world. There is no one laboratory or radiological test that is used to diagnose it. Various routine and novel blood markers have been identified, however none have proved to be conclusive. The aim of this study was to combine routine blood markers to increase the sensitivity and specificity in diagnosing histologically confirmed appendicitis. Methods We retrospectively reviewed the theatre logs for the calendar year of 2015 to identify all of the appendectomies which were performed. We reviewed all of the admission bloods for the patients - including their white blood cell (WBC) count, their neutrophil count, and their C-Reactive protein (CRP) value. We also reviewed all of the histology to identify the inflamed appendices, and analysed all of this information together. Results The neutrophil count is the most sensitive of the three blood markers with a score of 82%. It has a specificity of 63%. The CRP value is the most specific of the three blood markers with a value of 67% and a sensitivity of 76%. WBC has a sensitivity of 75% and a specificity of 63%. Combining all of the blood values (i.e. elevated white blood cell count or elevated neutrophil count or elevated CRP) demonstrates a sensitivity of 96% and a specificity of 45%. Conclusion Combining routine admission blood markers (WBC, neutrophil count, and CRP) can assist in diagnosing appendicitis in unwell patients with abdominal pain.

Perioperative steroid administration improves knee function and reduces opioid consumption in bilateral total knee arthroplasty.

INTRODUCTION: The benefits of steroid usage have been well described for unilateral total knee arthroplasty (TKA), however it's benefits in bilateral TKA has not been well published in the literature. We describe the impact of perioperative steroid administration in a cohort of bilateral TKAs (74 knees) with regard to immediate postoperative knee function, postoperative knee strength and opioid consumption. MATERIALS AND METHODS: We report on a single-surgeon consecutive case series of simultaneously-performed bilateral TKAs. Eighteen patients received 2 doses of 8 mg IV dexamethasone in the perioperative setting. There were 19 patients in the control group. Primary outcome measures were day 1 postoperative knee flexion (degrees), knee strength and postoperative analgesic requirements (mg/mcg). Morphine dose equivalents (MDE) were calculated to compare all opioid-based analgesics. Secondary outcomes included post-operative pain according to the VAS (at 24, 48 and 72 h), anti-emetic requirements (mg) and length of stay (days). RESULTS: The mean knee flexion achieved day 1 in the steroid group was 70.1°(σ = 17.64, 95% CI 64.1-76.0) compared to 55.8° in the non-steroid group (σ = 19.8, 95% CI 49.2-62.3) (p = 0.0008). Regarding the straight leg raise, 88.9% of the steroid group were able to achieve this compared to only 55.2% of the non-steroid group (p = 0.002). There was a reduction in the MDE requirement per patient across all medications for the 'steroid' group. Both Targin® (p = 0.03) (Prolonged-Release Oxycodone) and Fentanyl (p = 0.01) requirements were significantly reduced in the 'steroid' group. CONCLUSION: We recommend the use of perioperative steroids in bilateral TKA to allow accelerated rehabilitation, improved immediate knee function and an overall reduction in the consumption of potentially problematic opioid-based analgesics.

Microbiome and health implications for ethnic minorities after enforced lifestyle changes.

Modern lifestyles increase the risk of chronic diseases, in part by modifying the microbiome, but the health effects of lifestyles enforced on ethnic minorities are understudied1-3. Lifestyle affects the microbiome early in life, when the microbiome is assembled and the immune system is undergoing maturation4-6. Moreover, the influence of lifestyle has been separated from genetic and geographic factors by studies of genetically similar populations and ethnically distinct groups living in the same geographic location7-11. The lifestyle of Irish Travellers, an ethnically distinct subpopulation, changed with legislation in 2002 that effectively ended nomadism and altered their living conditions. Comparative metagenomics of gut microbiomes shows that Irish Travellers retain a microbiota similar to that of non-industrialized societies. Their microbiota is associated with non-dietary factors and is proportionately linked with risk of microbiome-related metabolic disease. Our findings suggest there are microbiome-related public health implications when ethnic minorities are pressured to change lifestyles.

High rate of tibial debonding and failure in a popular knee replacement: A cause for concern.

BACKGROUND: Total knee arthroplasty (TKA) is a common orthopedic procedure with 975,739 performed in the UK between 2003 and 2016. The two most common prosthetics used are P.F.C. Sigma and NexGen. The aim of this study is to compare the experience of a single fellowship-trained arthroplasty surgeon at a single dedicated orthopedic hospital using both of these prosthetics over a 17-year period. METHODS: This study was carried out as a retrospective review. Information was gathered from a database of primary TKAs and revision TKAs, as well as medical records, correspondence and operative notes. RESULTS: A total of 1,511 TKAs were performed between 1999 and 2015 - with a further follow-up period of 2 years. There were 1,161 consecutive P.F.C. primary TKAs done from 1999 to April 2013, after which, 350 consecutive NexGen primary TKAs were performed. Between 2015 and 2017, 26 NexGen revisions were required. 23 (6.6%) of the NexGen knees were carried out for aseptic loosening. The average time for revision from the NexGen index surgery was 30.4 months. The failures all presented similarly - with the tibial component having collapsed into varus and radiographic lucency noted under the implant. CONCLUSION: In spite of changes in orthopedic practice and advances in implant technology over the time period of this study, we would not expect this level of implant failure from a surgeon who had no previous significant issues with aseptic loosening using a different prosthetic. Usage of the NexGen knee has been discontinued at this center.

Gut microbiota alterations associated with reduced bone mineral density in older adults.

OBJECTIVE: To investigate compositional differences in the gut microbiota associated with bone homeostasis and fractures in a cohort of older adults. METHODS: Faecal microbiota profiles were determined from 181 individuals with osteopenia (n = 61) or osteoporosis (n = 60), and an age- and gender-matched group with normal BMD (n = 60). Analysis of the 16S (V3-V4 region) amplicon dataset classified to the genus level was used to identify significantly differentially abundant taxa. Adjustments were made for potential confounding variables identified from the literature using several statistical models. RESULTS: We identified six genera that were significantly altered in abundance in the osteoporosis or osteopenic groups compared with age- and gender-matched controls. A detailed study of microbiota associations with meta-data variables that included BMI, health status, diet and medication revealed that these meta-data explained 15-17% of the variance within the microbiota dataset. BMD measurements were significantly associated with alterations in the microbiota. After controlling for known biological confounders, five of the six taxa remained significant. Overall microbiota alpha diversity did not correlate to BMD in this study. CONCLUSION: Reduced BMD in osteopenia and osteoporosis is associated with an altered microbiota. These alterations may be useful as biomarkers or therapeutic targets in individuals at high risk of reductions in BMD. These observations will lead to a better understanding of the relationship between the microbiota and bone homeostasis.

Four men in a boat: Ultra-endurance exercise alters the gut microbiome.

OBJECTIVES: Compositional and functional adaptions occur in the gut microbiome in response to habitual physical activity. The response of the gut microbiome to sustained, intense exercise in previously active individuals, however, is unknown. This study aimed to prospectively explore the gut microbiome response of four well-trained male athletes to prolonged, high intensity trans-oceanic rowing, describing changes in microbial diversity, abundance and metabolic capacity. DESIGN: A prospective, repeated-measures, within-subject report. METHODS: Serial stool samples were obtained from four male athletes for metagenomic whole-genome shotgun sequencing to record microbial community structure and relevant functional gene profiles before, during and after a continuous, unsupported 33-day, 5000 km transoceanic rowing race. Calorific intake and macronutrient composition were recorded by validated food frequency questionnaire and anthropometry was determined by body composition analysis and cardiorespiratory testing. RESULTS: Microbial diversity increased throughout the ultra-endurance event. Variations in taxonomic composition included increased abundance of butyrate producing species and species associated with improved metabolic health, including improved insulin sensitivity. The functional potential of bacterial species involved in specific amino and fatty acid biosynthesis also increased. Many of the adaptions in microbial community structure and metaproteomics persisted at three months follow up. CONCLUSIONS: These findings demonstrate that prolonged, intense exercise positively influences gut microbial diversity, increases the relative abundance of some bacterial species and up-regulates the metabolic potential of specific pathways expressing microbial gene products. These adaptions may play a compensatory role in controlling the physiological stress associated with sustained exertion as well as negating the deleterious consequences accompanying endurance exercise.

A Repeated-measures Case Series of Physiological Responses to a Transoceanic Rowing Race.

This repeated-measures case series describes the changes in cardiorespiratory fitness, body composition and systemic inflammation in 4 well-trained athletes pre- and post-completion of an unsupported transatlantic rowing race. The acute effects of endurance exercise have been well described previously, but the enduring consequences of ultra-endurance on the cardiorespiratory, metabolic and immune systems are largely unknown. This study explores these physiological adaptations following 2 weeks of recovery. Cardiorespiratory fitness testing, body composition analysis, and blood sampling for inflammatory cytokines were recorded immediately before race departure and repeated 14 days following race completion. Mean VO2max (ml/kg/min) was similar pre- (48.2±2.8) and post-race (46.7±1.5). Heart rate responses were equivalent at incremental workloads. Mean blood lactate (mmol/L) was higher at low to moderate power outputs and lower at maximal effort (14.6±1.85 vs. 13.1±2.5). Percentage body fat (17.7 ± 7.9 vs. 16.2±7.4) was analogous to pre-race analysis. Low-grade inflammation persisted, indicated by an increase in IL-1ß (69%), IL-8 (10%), TNF-α (8%), IL-6 (5.4%), and C-reactive protein (22.4%). VO2max and heart rate responses were similar pre- and post-race, but sub-maximal efficiency measures of cardiorespiratory fitness were consistent with persistent fatigue. Body composition had returned to baseline but low-grade systemic inflammation persisted. Persistent pro-inflammatory cytokinaemia is known to exert deleterious consequences on immune, metabolic, and psychological function. Adequate recovery is necessary to re-establish inflammatory homeostasis, and the results of this study may inform these decisions.