A multicentre comparative analysis of fixation versus revision surgery for periprosthetic femoral fractures following total hip arthroplasty with a cemented polished taper-slip femoral component.

AIMS: The aim of this study was to compare open reduction and internal fixation (ORIF) with revision surgery for the surgical management of Unified Classification System (UCS) type B periprosthetic femoral fractures around cemented polished taper-slip femoral components following primary total hip arthroplasty (THA). METHODS: Data were collected for patients admitted to five UK centres. The primary outcome measure was the two-year reoperation rate. Secondary outcomes were time to surgery, transfusion requirements, critical care requirements, length of stay, two-year local complication rates, six-month systemic complication rates, and mortality rates. Comparisons were made by the form of treatment (ORIF vs revision) and UCS type (B1 vs B2/B3). Kaplan-Meier survival analysis was performed with two-year reoperation for any reason as the endpoint. RESULTS: A total of 317 periprosthetic fractures (in 317 patients) with a median follow-up of 3.6 years (interquartile range (IQR) 2.0 to 5.4) were included. The fractures were type B1 in 133 (42.0%), B2 in 170 (53.6%), and B3 in 14 patients (4.4%). ORIF was performed in 167 (52.7%) and revision in 150 patients (47.3%). The two-year reoperation rate (15.3% vs 7.2%; p = 0.021), time to surgery (4.0 days (IQR 2.0 to 7.0) vs 2.0 days (IQR 1.0 to 4.0); p < 0.001), transfusion requirements (55 patients (36.7%) vs 42 patients (25.1%); p = 0.026), critical care requirements (36 patients (24.0%) vs seven patients (4.2%); p < 0.001) and two-year local complication rates (26.7% vs 9.0%; p < 0.001) were significantly higher in the revision group. The two-year rate of survival was significantly higher for ORIF (91.9% (standard error (SE) 0.023%) vs 83.9% (SE 0.031%); p = 0.032) compared with revision. For B1 fractures, the two-year reoperation rate was significantly higher for revision compared with ORIF (29.4% vs 6.0%; p = 0.002) but this was similar for B2 and B3 fractures (9.8% vs 13.5%; p = 0.341). The most common indication for reoperation after revision was dislocation (12 patients; 8.0%). CONCLUSION: Revision surgery has higher reoperation rates, longer surgical waiting times, higher transfusion requirements, and higher critical care requirements than ORIF in the management of periprosthetic fractures around polished taper-slip femoral components after THA. ORIF is a safe option providing anatomical reconstruction is achievable.Cite this article: Bone Joint J 2023;105-B(2):124-134.

Spondylodiscitis-a cohort analysis of its identification and management.

PURPOSE: Discitis represents infection of the intervertebral disc and osteomyelitis of the adjacent end plates. Classically, patients present with fever and back pain. Varied presentations and lack of adherence to guidelines lead to great variation in its identification and management. The primary objective of this study was to conduct a cohort analysis, assessing the identification and management of discitis, in a busy secondary orthopaedic centre. METHODS: A retrospective study was conducted, of cases diagnosed and treated for discitis, in a secondary orthopaedic department, within the UK from January 2017 to October 2019. During this time period, all patients who underwent magnetic resonance imaging (MRI) spine were identified. Patients with MRI-proven discitis were then added into the study. RESULTS: A total of 152 MRIs showed radiographic features of discitis. Of these, only 38 had a clear clinical correlation. Back pain was the most common presenting complaint followed by fever. The commonest site of involvement was vertebral levels L5 and S1. All patients had baseline bloods, and most, but not all, had blood cultures taken. Staphylococcus aureus was the most frequently isolated, causative organism. The mainstay of treatment was intravenous flucloxacillin, with most patients requiring a minimum of six weeks. CONCLUSION: Our study has helped define the population of patients presenting with discitis, in a busy secondary orthopedic center. Analyzing over two years of data has provided us with valuable insight into the most appropriate diagnostics and management for discitis.

Outpatient Parenteral Antimicrobial Therapy Practice in United Kingdom: A Single-center Experience.

Objectives: This study sought to analyze the outpatient parenteral antimicrobial therapy (OPAT) services provided by a tertiary hospital, in terms of types and duration of antimicrobials administered, and assess whether these services were in line with current good practice recommendations. Methods: The electronic healthcare records of all stable patients with infectious diseases, aged ≥ 18 years, who received OPAT services between January 2019 and March 2021, were analyzed. For statistical analysis, the patients were divided into younger (< 65 years) and older (≥ 65 years) adults and the difference between them, in terms of healthcare resources utilization, was assessed. Results: Over 27 months, 199 patients received OPAT services, resulting in saving of 7514 bed-days. Bone and joint infections (38.7%) were the predominant diagnoses. The median actual OPAT duration was significantly greater than the planned duration for the total study population, younger adults, and older adults (p < 0.050). Of 28 (14.1%) patients with adverse events, 25 were related to antimicrobials while the remaining three were associated with catheters. There were no significant differences between younger and older adults in the characteristics evaluated, except for the higher incidence of Staphylococcus aureus (p < 0.001) and Escherichia coli, Staphylococcal spp., Streptococcal spp., and Pseudomonas spp. (p =0.003) infection in older adults. Conclusions: The actual median duration of OPAT therapy was significantly longer than planned, with suboptimal adherence to the principles of antimicrobial stewardship. OPAT has been shown to be safe for both younger and older adults.

Periprosthetic Femoral Fractures and Their Surgical Outcomes Between 2011 and 2021: A Single-Centre Observational Study.

Introduction Periprosthetic femoral fractures (PFFs) present a significant burden on the health service. The incidence continues to rise globally as a result of an ageing population and an increase in the number of primary hip and knee arthroplasties being performed. This is a 10-year, retrospective, observational study that aims to better understand the outcomes of PFF in our district general hospital. Materials and methods We identified the demographic information of patients who had a PFF and looked at how the American Society of Anesthesiologists (ASA) score, time to operation, length of stay, complications, and mortality data vary depending on where the fracture is sited and the operative management employed. Results During the period between January 2011 and March 2021, we identified 214 cases of PFF. The mean age was 82.5 years with a female preponderance of 76%. Between 2011-2016 and 2017-2021, the number of cases of PFF increased and patients with an ASA score of 3 or more increased from 43% to 73%. Length of stay was longer in the proximal PFF revision group than in the proximal PFF fixation group. Overall PFF mortality rates at 30 days, 90 days, and one year were 6%, 10%, and 15%, respectively. Conclusion Over the 10-year period, there was a significant increase in the incidence of patients presenting with PFF with multiple comorbidities. Mortality rates were lower in proximal PFF patients who underwent revision procedures rather than fixation. The patient demographics, complication rates, and mortality rates were comparable to similar studies across different countries.

Acculturation of international medical graduates into the NHS.

Since the inception of the NHS, international medical graduates (IMGs) have been recognised as integral to the NHS long-term plan. These diverse groups of doctors make up approximately a fifth of all licensed doctors in the UK. The NHS has a history of reliance on IMGs to fill shortages and add to the workforce. IMGs face numerous challenges while immigrating and starting a new job in the UK. Conversely, the employing hospital has a responsibility to help their new IMGs adapt to the UK system of medical practice. Keeping the above-mentioned concerns in mind and hoping to tackle these issues faced by IMGs, a clinical attachment programme has been initiated at Ashford and St Peter's Hospitals NHS Foundation Trust (ASPH) by a group of clinicians, administration staff and the medical director. Although there are various pathways for an IMG to enter the healthcare system in the UK, the ASPH has provided an organised programme that promises to deliver high-quality doctors that value patient safety. This article outlines the programme that can be adopted by other NHS trusts to acculturate and have a positive impact on the IMGs' careers, as well as their work-life balance.

The Effect of Type of Femoral Component Fixation on Mortality and Morbidity after Hip Hemiarthroplasty: A Systematic Review and Meta-Analysis.

BACKGROUND: Hip hemiarthroplasty is a well-established treatment of displaced femoral neck fracture, although debate exists over whether cemented or uncemented fixation is superior. Uncemented prostheses have typically been used in younger, healthier patients and cemented prostheses in older patients with less-stable bone. Also, earlier research has suggested that bone cement has cytotoxic effects and may trigger cardiovascular and respiratory adverse events. QUESTIONS/PURPOSES: The aim of this systematic review and meta-analysis was to compare morbidity and mortality rates after cemented and uncemented hemiarthroplasty for the treatment of displaced femoral neck fractures in elderly patients. METHODS: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched seven medical databases for randomized clinical trials and observational studies. We compared cemented and uncemented hemiarthroplasty using the Harris Hip Score (HHS), as well as measures of postoperative pain, mortality, and complications. Data were extracted and pooled as risk ratios or standardized mean difference with their corresponding 95% confidence intervals in a meta-analysis model. RESULTS: The meta-analysis included 34 studies (12 randomized trials and 22 observational studies), with a total of 42,411 patients. In the pooled estimate, cemented hemiarthroplasty was associated with less risk of postoperative pain than uncemented hemiarthroplasty. There were no significant differences between groups regarding HHS or rates of postoperative mortality, pulmonary embolism, cardiac arrest, myocardial infarction, acute cardiac arrhythmia, or deep venous thrombosis. CONCLUSIONS: While we found that cemented hemiarthroplasty results in less postoperative pain than uncemented hemiarthroplasty in older patients with femoral neck fracture, the lack of significant differences in functional hip scores, mortality, and complications was surprising. Further high-level research is needed.

Tackling the elective case backlog generated by Covid-19: the scale of the problem and solutions.

BACKGROUND: In April 2020, Covid-19 brought NHS elective procedures to a halt. The aim of this paper is to produce accurate forecasts on the building backlog, highlight the state of waiting lists currently and propose solutions required to prevent a public health crisis. METHOD: Using data published by NHS digital and NHS England on previous years, we have analysed and used this to produce estimates of cancellations and missed cases. We also analyse government data on waiting lists and show compliance or lack of with these. RESULTS: We show that compliance with waiting list times pre pandemic was falling year on year (83.2% in 2020 down from 87% in 2019). Every month that passes we estimate that 400 000 cases are not being performed. This may include urgent cancer care work in some trusts. CONCLUSIONS: Waiting lists have been governed by strict rules since 2004. Given falling compliance with 18-week intention to treat we believe the scale of the backlog combined with NHS capacity diminished due to Covid-19 precautions is a public health crisis waiting to occur. We identify difficulties in resuming elective work and suggest strategies that could be employed to avoid a public health crisis.

Outcome of trauma and orthopaedic surgery at a UK District General Hospital during the Covid-19 pandemic.

INTRODUCTION: There are suggestions that elective surgery performed during the incubation period of COVID-19 infection may cause an immediate impairment of cell-mediated immunity, leading to high morbidity and mortality. However is contrasting data about the associated mortality. Since the outbreak, our unit has maintained a prospective database recording Trauma and Orthopaedic surgical activity. Our aim was to share our experience of the first 3 months with prospective data on outcome of essential surgery during the covid-19 peak. Our focus in this report was on the mortality rate as services begin to open. Methods: We prospectively collected data during the peak of the pandemic in the UK, for fracture neck of femur patients (NOF) the most commonly performed surgical procedure and the most vulnerable during this period. We compared this Covid-19 cohort of NOFs against a cohort of NOF's during the same time in 2019 and another cohort of NOF's in 2020 outside the lockdown period to compare mortality rates and give a broader perspective. RESULTS: During the period March 1, 2020 to May 31, 2020, total of 206 patients were operated. Ninety-four fracture NOF and another one hundred twelve essential surgical procedures were performed. In the NOF cohort, there were nine patients that died. Three of them were covid-19 positive, one was not tested and the rest five were covid-19 negative. There was no mortality reported in the non NOF group. Conclusion: In our unit, during the lock down period, mortality rate in patients undergoing fracture NOF was not significantly different from a similar cohort earlier in the year and similar period last year. We have not observed any mortality, to date in the Non NOF procedures carried out.

Subscapularis tenotomy versus lesser tuberosity osteotomy during total shoulder replacement: a comparison of patient outcomes.

BACKGROUND: Two different techniques to release the subscapularis during total shoulder replacement (TSR) have been described: tenotomy and osteotomy. We review the clinical outcomes of a sequential series of patients in whom a TSR for primary osteoarthritis had been performed by either technique at our institution. Subscapularis function was tested by a new graded belly-press test. MATERIALS AND METHODS: All patients who underwent surgery between January 2002 and January 2010, and met the eligibility criteria, were included for analysis. Subscapularis function was assessed postoperatively with a range of functional assessments, including the graded belly-press test and lift-off test, as well as assessment of each patient's range of movement. RESULTS: A total of 36 shoulders in 36 patients were subsequently reviewed, 10 of whom underwent tenotomy and 26 of whom underwent osteotomy. Patients who had undergone osteotomy of the lesser tuberosity had a more favorable outcome overall. These patients showed a trend toward a better range of movement, although no statistical significance was shown. They had a better grade (grade 1) on the belly-press test compared with the tenotomy group (P = .026). All patients (osteotomy and tenotomy) with a grade 1 belly-press test had a better clinical outcome with data showing statistical significance. CONCLUSION: Our results indicate that in this single-surgeon sequential series, patients who underwent osteotomy of the lesser tuberosity during TSR for osteoarthritis had a better functional outcome than those who had a subscapularis tenotomy as assessed by the graded belly-press test.