Controversies around hip fracture treatment: clinical evidence versus trends from national registries.

PURPOSE: Several controversies in the optimal treatment of femoral neck fractures persist, together with large variations in clinical practice. METHODS: A narrative literature review covering 4 current controversies in the surgical management of femoral neck fractures (total hip arthroplasty (THA) versus hemiarthroplasty (HA), cemented versus uncemented HA, internal fixation versus arthroplasty, operative versus non-operative) was performed. Available literature was balanced against annual trends in the management of femoral neck fractures from the public domain of several national registries (Sweden, Norway, The Netherlands, Australia and New Zealand). RESULTS: For most controversies, the literature provides stronger evidence than is reflected by variations encountered in daily practice. Implementation of clinical evidence tends to lag behind and important differences exist between countries. CONCLUSIONS: Trends of clinical practice from national registries indicate that implementation of available clinical evidence needs to be improved.

Revision risk of salvage compared with acute total hip arthroplasty following femoral neck fracture: an analysis from the Dutch Arthroplasty Register.

BACKGROUND AND PURPOSE: There is no consensus on the treatment of patients with femoral neck fractures between internal fixation (IF) or directly treated with a total hip arthroplasty (fracture-THA) in particular for the age group 60-70 years. Failure of IF is not uncommon, resulting in salvage total hip arthroplasty (salvage-THA). The aim of our study was to compare revision rates of salvage-THA with fracture-THA and osteoarthritis (OA)-THA. PATIENTS AND METHODS: Revision rates and reasons for revision were compared. Data collected in the Dutch Arthroplasty Register (LROI) between 2007 and 2018 was used. The study included 4,310 salvage-THAs, 12,159 fracture-THAs, and 274,147 OA-THAs. We performed Kaplan-Meier survival analyses and Cox regression to evaluate THA survival. RESULTS: No statistically significant difference in revision rates between salvage-THAs and fracture-THAs was found (HR 1.0, 95% CI 0.7-1.3) whereas the revision rate was higher compared with OA-THAs (HR 1.3, CI 1.0-1.5). The 5-year revision rate was 5.0% (CI 4.4-5.8) in salvage-THAs, 4.5% (CI 4.1-5.0) in fracture-THAs, and 3.1% (CI 3.0-3.2) in OA-THAs. A higher revision rate for infection was found in salvage-THAs in comparison with fracture-THAs (HR 1.6, CI 1.0-2.3). CONCLUSION: We found no difference in revision rates for salvage-THAs compared with fracture-THAs. The risk of revision for infection was higher for salvage-THA.

Increased failure rates after the introduction of the TFNA proximal femoral nail for trochanteric fractures: implant related or learning curve effect?

Background and purpose - Trochanteric fractures are often treated using intramedullary fixation. In our institution, the TFN-Advanced Proximal Femoral Nailing System (TFNA) was introduced as replacement for the Gamma Trochanteric Nail (GTN3) for the treatment of these fractures as a result of a hospital-driven change of trauma implant supplier. We compared trochanteric fracture fixation failure rate between these 2 intramedullary nails. Patients and methods - All trochanteric fractures treated surgically from 2011 to 2019 were retrospectively reviewed for fixation failure. From 2016 only the TFNA was used. Fixation failure was defined as implant cut-out, implant breakage, non-union, malpositioning of the screw/blade requiring reoperation, new fracture around the nail, or miscellaneous. Propensity score matching was used to balance distribution of covariates and to compare failure rates between TFNA and GTN3 groups. Learning curve analyses were performed. Results - After exclusion, 797 GTN3s (779 patients) and 542 (536 patients) TFNAs were available for analysis. A higher risk of fixation failure was found in the TFNA group (14%) compared with the GTN3 group (7.0%) (hazard ratio [HR] 2.0, 95% confidence interval [CI] 1.2-3.5). This was mainly attributed to a higher risk of cut-out (HR 2.2; CI 0.9-5.7), malpositioning (HR 4.7; CI 0.7-34), and new fracture around the nail (HR 4.0; CI 1.0-16). Learning curve analyses indicated no clear learning curve effect. Interpretation - Failure of fixation increased after a switch from the GTN3 to the TFNA proximal femoral nail for the treatment of trochanteric fractures. Cut-out and malpositioning of the calcar screw or blade appeared to be the most dominant failure mechanisms. Modifications in implant design may have played a role in this increased risk of failure of fixation. In our institution a new implant device was introduced without solid clinical evidence behind it. This study may help to underline the need for medical doctors with a critical and scientific background to be involved in implant choices.

Nonoperative management of hip fractures in very frail elderly patients may lead to a predictable short survival as part of advance care planning.

Background and purpose - Surgical treatment is still the mainstay of care even in very frail elderly hip fracture patients. However, one may argue whether surgery is in the best interest of all patients. We elucidated mortality rates of nonoperative management (NOM) of a hip fracture after shared decision-making in a cohort of very frail elderly patients.Patients and methods - Orthogeriatric patients (age > 70 years) admitted with a hip fracture between 2011 and 2019 were included. In the presence of fragility features the motivation for surgery or NOM was supported by advance care planning (ACP) and shared decision-making through geriatric assessment. Mortality rates after NOM were assessed and also presented for the remaining surgical group for reference.Results - In 1,279 out of 3,467 patients, geriatric assessment was indicated and subsequently 1,188 (93%) had surgery versus 91 (7%) NOM. The motivation for NOM was based on patient and family preferences in only 20% of patients, medical grounds in 54%, and a combination of both in 26%. The 30-day and 1-year mortality in the frail NOM group was 87% and 99% respectively, whereas this was 7% and 28% in the surgery group. No statistical comparison between groups was performed due to profound bias by indication.Interpretation - This study provides further insight into the predictable and high short-term mortality after NOM in carefully selected very frail elderly hip fracture patients. This information may help to consider NOM as an alternative treatment option to surgery when no significant gain from surgery is anticipated.

The (un)necessity of regular postoperative follow-up of hemiarthroplasty for femoral neck fractures.

BACKGROUND: Postoperative follow-up after hemiarthroplasty is part of routine based practice. However, these visits appear to be a significant burden since it concerns a frail population. The aim of this study was to confirm the current common practice regarding postoperative visits of patients treated with hemiarthroplasty and to evaluate the complication detection rate at these visits. METHODS: A national short survey was conducted among orthopedic surgeons working in 26 large Dutch teaching hospitals to test the hypothesis that postoperative follow-up is indeed common practice. Furthermore, a retrospective patient review was performed in all hemiarthroplasties implanted between January 2014 and December 2019. RESULTS: The response of the national survey was complete and showed that postoperative follow-up in patients treated with hemiarthroplasty is part of standard care according to 89% of respondents. A total of 1055 hips (1026 patients) were implanted with hemiarthroplasty during the studied period. Implant-related complications were identified in 68 hemiarthroplasties, with 31 of these hips going on to reoperation. Only 2 of these complications were picked up at standard planned follow-up leading to a complication detection rate of 0.3%. In contrast, complication detection rates of 47% and 16% were found at unplanned visits at the Emergency Department and the outpatient department, respectively. CONCLUSIONS: Postoperative follow-up in patients treated with hemiarthroplasty is still the standard of care. However, this study revealed that the majority of implant-related complications are detected at unplanned visits and almost no at standard follow-up visits. Postoperative follow-up of patients treated with hemiarthroplasty could be abandoned in this frail population.

A Swallowing Screening Test Enhances a Better Recognition of Patients with a Hip Fracture at Risk for Oropharyngeal Dysphagia.

Oropharyngeal dysphagia (OD) is commonly encountered in elderly patients with hip fracture. It is easily overlooked and predisposes patients to life-threatening postoperative pneumonia. The aim of this study was to evaluate whether OD screening by nurses results in a better recognition of patients at risk for OD. After the introduction of the Standardized Swallowing Assessment by nurses, the incidence of increased risk for OD and the prevention of OD complications were monitored (intervention group; N = 92) and compared with a historical control group (N = 81). The risk for OD was diagnosed in 27 patients (29%) in the intervention group in comparison with 12 patients (15%) in the control group (p < .05). The number of diet modifications increased from 12 (15%) in the control group to 25 (27%) in the intervention group (p < .05). A simple screening test results in better recognition of increased OD risk and, in turn, the early initiation of measures to avoid aspiration.

The Effect of Percutaneous Flexor Tenotomy on Healing and Prevention of Foot Ulcers in Patients With Claw Deformity of the Toe.

Claw deformity of the foot is frequently seen in patients with diabetes mellitus. Percutaneous flexor tenotomy is a simple surgical procedure for the treatment of foot ulcers on the distal end of the toe caused by this deformity. This procedure can also be performed to prevent ulcers in claw toes that are at risk of ulceration. The aim of this study is to investigate whether percutaneous flexor tenotomy is an effective surgical method for treatment and prevention of toe ulcers in patients with claw deformity. This retrospective study, with a median follow-up of 13.4 (1 to 66.7) months, included all consecutive patients who underwent percutaneous flexor tenotomy in 2 hospitals between July 2012 and April 2017. In total, 101 feet underwent flexor tenotomy: 84 (83.3%) therapeutic and 17 (16.7%) prophylactic. Of the 84 therapeutic procedures, 95.1% healed, with a median healing time of 27 days. In 11 (13.3%) therapeutic procedures, a reulceration was recorded. In the therapeutic group, 4 (4.8%) infections and 1 (1.2%) amputation of the digit occurred. In the 17 prophylactic procedures, local bleeding was recorded in 1 (5.9%). In the prophylactic group, 2 ulcers occurred. In 77 (76.2%) of all procedures, patients had diabetes mellitus. In conclusion, percutaneous flexor tenotomy is an effective, safe, and minimally invasive procedure for the treatment and prevention of toe ulcers in patients with claw deformity.

Effects of TNT contaminated soil on vegetation at an explosive range by probing UPLC-qTOF MS profiling method.

Three tree species (Wild olive, Stinkwood and Cape Holy) and a shrub (Dovyalis caffra) were each potted in 20 L pots in order to evaluate the effect of 1,3,5-trinitrotoluene (TNT)-contaminated soil on vegetation. TNT contamination was established by dissolving flake TNT in acetone at 300 and 600 mg per kilogram soil concentrations. One pot for every species was left uncontaminated as control elements. A set of 16 samples, four contaminated, four uncontaminated aerial parts and their corresponding soils, were gathered. These were processed and subjected to a solid phase extraction method to isolate analytes of interest. A laboratory analytical method was applied using ultra-performance liquid chromatography coupled to quadrupole time-of-flight mass spectrometry (UPLC-qTOF MS). For the UPLC-qTOF MS a gradient for the mobile phase was found which allowed the profiling and separation of metabolites in the aerial parts of the vegetation. This method allowed identification and quantification of major changes caused by TNT contaminated soil on vegetation. The Synapt High Definition Mass Spectrometer SYNAPT HDMS G1 was operated using the electrospray ionisation (ESI) technique in both positive and negative mode. A clear comparison of profiles was achieved and this has been demonstrated by the distinct newly-formed metabolites in the TNT contaminated vegetation understudy. The results have also shown that the chlorophyll region in the contaminated profile was also affected by the uptake of TNT degradation products. This has been observed in the contaminated profiles of Wild olive, Stinkwood and Cape Holly extracts indicating enhanced nutrient availability.

3D Navigo™ versus TRUS-guided prostate biopsy in prostate cancer detection.

INTRODUCTION: To overcome the limitations regarding transrectal ultrasound (TRUS)-guided biopsies in prostate cancer (PCa) detection, there is a focus on new imaging technologies. The Navigo™ system (UC-care, Israel) uses regular TRUS images and electrospatial monitoring to generate a 3D model of the prostate. The aim of this study was to compare cancer detection rates between the Navigo™ system and conventional TRUS, in patients without a history of PCa. METHODS: We performed a retrospective study by collecting data from all patients who underwent 12-core prostate biopsies from lateral peripheral zones between September 2013 and February 2015 at the Jeroen Bosch Hospital in 's-Hertogenbosch (Netherlands). RESULTS: A total of 325 patients met our inclusion criteria. 77.8 % of biopsy sessions were performed using the Navigo™ system. There was no statistically significant difference in PCa detection (39.9 vs 46.2 % with Navigo™ system and TRUS, respectively). Using the Navigo™ system for taking prostate biopsies proved not to be associated with the presence of PCa at biopsy, likewise for clinically significant PCa and for both subgroups. LIMITATIONS: The limitations of the study include its retrospective design, the limited number of patients in the conventional TRUS group, the statistically significant different number of biopsy sessions and the ones performed by an advanced physician in both groups. CONCLUSION: In our study, there is no added value of 3D TRUS using Navigo™ system compared to conventional 2D TRUS regarding PCa detection in biopsy-naive men and men with prior negative biopsy.

RhD negativity among pregnant women in multiethnic Suriname.

BACKGROUND: RhD negativity is distributed unevenly among different ethnicities. In this study we explored the frequencies of RhD negativity in pregnant women in multiethnic Suriname, along with screening results for red blood cell (RBC) antibodies in these women and their offspring. Results may help identify women at risk for hemolytic disease of the fetus and newborn. STUDY DESIGN AND METHODS: A retrospective study was performed in pregnant women who delivered at three major hospitals in Suriname between January 1, 2013, and December 31, 2014. RESULTS: The overall prevalences of RhD negativity among 8686 women was 4.3%. The percentages of RhD negativity in Maroons, Creoles, and Hindustani women were 7.2, 5.4, and 3.7%, respectively. Chinese and Javanese women had very low prevalences of 0.8 and 0.5%, respectively, and Amerindians showed no RhD negativity. Antibody screening was positive in six D- (five Maroons and one Creole) women and weakly positive in three women (two Creoles and one Maroon), making overall antibody prevalence 4.4%. In 15 (5.5%; 10 Maroons, four Creoles, one Chinese) newborns from D- mothers antibody screening was positive. CONCLUSION: In the multiethnic Surinamese population RhD negativity among pregnant women varied between 0.0 and 7.2% between ethnic groups. RBC antibodies were detected during pregnancy and in newborns in 4.4 and 5.5%, respectively.

The impact of flooding on people living with HIV: a case study from the Ohangwena Region, Namibia.

BACKGROUND: Floods are a disaster situation for all affected populations and especially for vulnerable groups within communities such as children, orphans, women, and people with chronic diseases such as HIV and AIDS. They need functioning health care, sanitation and hygiene, safe water, and healthy food supply, and are critically dependent on their social care and support networks. A study carried out in the Ohangwena region, Namibia, where HIV prevalence is high and extensive flooding frequently occurs, aims to provide a deeper understanding of the impact that flooding has on people living with HIV (PLWHIV) as well as on HIV service providers in the region. DESIGN: The qualitative research applying grounded theory included semi-structured interviews with PLWHIV, focus group discussions with HIV service providers, and a national feedback meeting. The findings were interpreted using the sustainable livelihoods framework, the natural hazard research approach, and health behaviour theories. RESULTS: The study reveals that flooding poses major problems to PLWHIV in terms of their everyday lives, affecting livelihoods, work, income, and living conditions. The factors threatening them under normal conditions - poverty, malnutrition, unsafe water, sanitation and hygiene, limited access to health facilities, a weak health status, and stigma - are intensified by flood-related breakdown of infrastructure, insecurity, malnutrition, and diseases evolving over the course of a flood. A potential dual risk exists for their health: the increased risk both of infection and disease due to the inaccessibility of health services and antiretroviral treatment. A HIV and Flooding Framework was developed to display the results. CONCLUSIONS: This study demonstrates that vulnerabilities and health risks of PLWHIV will increase in a disaster situation like flooding if access to HIV prevention, treatment, care and support are not addressed and ensured. The findings and the HIV and Flooding Framework are not specific to Ohangwena and can be transferred to any flood-affected region that has a high HIV prevalence and relies mainly on subsistence agriculture. They serve as a model case for analysing vulnerabilities related to health and health service provision under disaster conditions. The impact will vary according to the physical, geographical, climatological, social, and behavioural characteristics of the region and the people affected. In the Ohangwena region, a disaster risk management mechanism is already in place which addresses people with HIV during flooding. However, preparedness could be improved further by applying the HIV and Flooding Framework.

Small changes in bone structure of female α7 nicotinic acetylcholine receptor knockout mice.

BACKGROUND: Recently, analysis of bone from knockout mice identified muscarinic acetylcholine receptor subtype M3 (mAChR M3) and nicotinic acetylcholine receptor (nAChR) subunit α2 as positive regulator of bone mass accrual whereas of male mice deficient for α7-nAChR (α7KO) did not reveal impact in regulation of bone remodeling. Since female sex hormones are involved in fair coordination of osteoblast bone formation and osteoclast bone degradation we assigned the current study to analyze bone strength, composition and microarchitecture of female α7KO compared to their corresponding wild-type mice (α7WT). METHODS: Vertebrae and long bones of female 16-week-old α7KO (n = 10) and α7WT (n = 8) were extracted and analyzed by means of histological, radiological, biomechanical, cell- and molecular methods as well as time of flight secondary ion mass spectrometry (ToF-SIMS) and transmission electron microscopy (TEM). RESULTS: Bone of female α7KO revealed a significant increase in bending stiffness (p < 0.05) and cortical thickness (p < 0.05) compared to α7WT, whereas gene expression of osteoclast marker cathepsin K was declined. ToF-SIMS analysis detected a decrease in trabecular calcium content and an increase in C4H6N(+) (p < 0.05) and C4H8N(+) (p < 0.001) collagen fragments whereas a loss of osteoid was found by means of TEM. CONCLUSIONS: Our results on female α7KO bone identified differences in bone strength and composition. In addition, we could demonstrate that α7-nAChRs are involved in regulation of bone remodelling. In contrast to mAChR M3 and nAChR subunit α2 the α7-nAChR favours reduction of bone strength thereby showing similar effects as α7ß2-nAChR in male mice. nAChR are able to form heteropentameric receptors containing α- and ß-subunits as well as the subunits α7 can be arranged as homopentameric cation channel. The different effects of homopentameric and heteropentameric α7-nAChR on bone need to be analysed in future studies as well as gender effects of cholinergic receptors on bone homeostasis.

The zeta potential of PMMA in contact with electrolytes of various conditions: theoretical and experimental investigation.

Many unit operations required in microfluidics can be realised by electrokinetic phenomena. Electrokinetic phenomena are related to the presence of electrical surface charges of microfluidic substrates in contact with a liquid. As surface charges cannot be directly measured, the zeta potential is considered as the relevant parameter instead. PMMA is an attractive microfluidic substrate since micron-sized features can be manufactured at low costs. However, the existence of PMMA surface charges is not well understood and the zeta potential data found in the literature show significant disagreement. In this article, we present a thorough investigation on the zeta potential of PMMA. We use computations of the potential distribution in the electrical double layer to predict the influence of various electrolyte parameters. The generated knowledge is compared to extensive experiments where we investigate the influence of ionic strength, pH, temperature and the nature of the electrolyte. Our findings imply that two different mechanisms influence the zeta potential depending on the pH value. We propose pure shielding in the acidic and neutral milieus while adsorption of co-ions occurs along with shielding in the alkaline milieu.

Quantification of calcium content in bone by using ToF-SIMS--a first approach.

The determination of the spatially resolved calcium distribution and concentration in bone is essential for the assessment of bone quality. It enables the diagnosis and elucidation of bone diseases, the course of bone remodelling and the assessment of bone quality at interfaces to implants. With time-of-flight secondary ion mass spectrometry (ToF-SIMS) the calcium distribution in bone cross sections is mapped semi-quantitatively with a lateral resolution of up to 1 µm. As standards for the calibration of the ToF-SIMS data calcium hydroxyapatite collagen scaffolds with different compositions were synthesized. The standards were characterised by loss of ignition, x-ray diffractometry (XRD) and x-ray photoelectron spectroscopy (XPS). The secondary ion count rate for calcium and the calcium content of the standards show a linear dependence. The obtained calibration curve is used for the quantification of the calcium content in the bone of rats. The calcium concentration within an animal model for osteoporosis induction is monitored. Exemplarily the calcium content of the bones was quantified by XPS for validation of the results. Furthermore a calcium mass image is compared with an XPS image to demonstrate the better lateral resolution of ToF-SIMS which advances the locally resolved quantification of the calcium content.

Bipolar coagulation with the BiClamp forceps versus conventional suture ligation: a multicenter randomized controlled trial in 175 vaginal hysterectomy patients.

PURPOSE: To compare bipolar vessel sealing (BVS; BiClamp) versus conventional suture ligation in vaginal hysterectomy. METHODS: A multicenter, single-blind randomized controlled trial (RCT) was conducted at eight women's hospitals in Germany. One hundred and seventy-five patients with benign uterine disease underwent vaginal hysterectomy using BVS (n = 88) or conventional suture ligation (n = 87 controls). Data analysis was based on intention-to-treat. RESULTS: Postoperative pain (primary endpoint) was decreased in the BVS group, but not significantly. Intraoperative blood loss was significantly lower in this group, with <100 mL recorded in 79/88 versus 52/86 patients (P < 0.001). Hemoglobin decrease indicated non-significantly lower blood loss in the BVS group. Operating time was significantly shorter in the BVS group than in the controls (38.0 +/- 18.6 vs. 48.0 +/- 24.9 min; P = 0.001). On average, 7.8 sutures/operation were saved with bipolar coagulation (P < 0.0001). Ease of use ratings were significantly higher for BVS. Hospital stay was similar for both groups. Adverse event rates did not differ significantly. CONCLUSIONS: The BiClamp procedure proved superior or similar to conventional ligation, particularly with regard to intraoperative blood loss, operating time and postoperative pain, although statistical significance was not attained for postoperative pain. Moreover, BVS was easier to use and more cost effective.