Despite the current trend favoring surgical treatment of displaced intra-articular calcaneal fractures (DIACFs), studies have not been able to demonstrate superior functional outcomes when compared to non-operative treatment. These fractures are notoriously difficult to reduce. Studies investigating surgical fixation often lack information about the quality of reduction even though it may play an important role in the success of this procedure. We wanted to establish if, amongst surgically treated DIACF, an anatomic reduction led to improved functional outcomes at 12 months. From July 2011 to December 2020, at a level I trauma center, 84 patients with an isolated DIACF scheduled for surgical fixation with plate and screws using a lateral extensile approach were enrolled in this prospective cohort study and followed over a 12-month period. Post-operative computed tomography (CT) imaging of bilateral feet was obtained to assess surgical reduction using a combination of pre-determined parameters: Böhler's angle, calcaneal height, congruence and articular step-off of the posterior facet and calcaneocuboid (CC) joint. Reduction was judged anatomic when Böhler's angle and calcaneal height were within 20% of the contralateral foot while the posterior facet and CC joint had to be congruent with a step-off less than 2 mm. Several functional scores related to foot and ankle pathology were used to evaluate functional outcomes (American Orthopedic Foot and Ankle Score - AOFAS, Lower Extremity Functional Score - LEFS, Olerud and Molander Ankle Score - OMAS, Calcaneal Functional Scoring System - CFSS, Visual Analog Scale for pain - VAS) and were compared between anatomic and nonanatomic DIAFCs using Student's t-test. Demographic data and information about injury severity were collected for each patient. Among the 84 enrolled patients, 6 were excluded while 11 were lost to follow-up. Thirty-nine patients had a nonanatomic reduction while 35 patients had an anatomic reduction (47%). Baseline characteristics were similar in both groups. When we compared the injury severity as defined by the Sanders’ Classification, we did not find a significant difference. In other words, the nonanatomic group did not have a greater proportion of complex fractures. Anatomically reduced DIACFs showed significantly superior results at 12 months for all but one scoring system (mean difference at 12 months: AOFAS 3.97, p = 0.12; LEFS 7.46, p = 0.003; OMAS 13.6, p = 0.002, CFSS 7.5, p = 0.037; VAS −1.53, p = 0.005). Univariate analyses did not show that smoking status, worker's compensation or body mass index were associated with functional outcomes. Moreover, fracture severity could not predict functional outcomes at 12 months. This study showed superior functional outcomes in patients with a DIACF when an anatomic reduction is achieved regardless of the injury severity

Despite the current trend favoring surgical treatment of displaced intra-articular calcaneal fractures (DIACFs), studies have not been able to demonstrate superior functional outcomes when compared to non-operative treatment. These fractures are notoriously difficult to reduce. Studies investigating surgical fixation often lack information about the quality of reduction even though it may play an important role in the success of this procedure. We wanted to establish if, amongst surgically treated DIACF, an anatomic reduction led to improved functional outcomes at 12 months. From July 2011 to December 2020, at a level I trauma center, 84 patients with an isolated DIACF scheduled for surgical fixation with plate and screws using a lateral extensile approach were enrolled in this prospective cohort study and followed over a 12-month period. Post-operative computed tomography (CT) imaging of bilateral feet was obtained to assess surgical reduction using a combination of pre-determined parameters: Böhler's angle, calcaneal height, congruence and articular step-off of the posterior facet and calcaneocuboid (CC) joint. Reduction was judged anatomic when Böhler's angle and calcaneal height were within 20% of the contralateral foot while the posterior facet and CC joint had to be congruent with a step-off less than 2 mm. Several functional scores related to foot and ankle pathology were used to evaluate functional outcomes (American Orthopedic Foot and Ankle Score - AOFAS, Lower Extremity Functional Score - LEFS, Olerud and Molander Ankle Score - OMAS, Calcaneal Functional Scoring System - CFSS, Visual Analog Scale for pain – VAS) and were compared between anatomic and nonanatomic DIAFCs using Student's t-test. Demographic data and information about injury severity were collected for each patient. Among the 84 enrolled patients, 6 were excluded while 11 were lost to follow-up. Thirty-nine patients had a nonanatomic reduction while 35 patients had an anatomic reduction (47%). Baseline characteristics were similar in both groups. When we compared the injury severity as defined by the Sanders’ Classification, we did not find a significant difference. In other words, the nonanatomic group did not have a greater proportion of complex fractures. Anatomically reduced DIACFs showed significantly superior results at 12 months for all but one scoring system (mean difference at 12 months: AOFAS 3.97, p = 0.12; LEFS 7.46, p = 0.003; OMAS 13.6, p = 0.002, CFSS 7.5, p = 0.037; VAS −1.53, p = 0.005). Univariate analyses did not show that smoking status, worker's compensation or body mass index were associated with functional outcomes. Moreover, fracture severity could not predict functional outcomes at 12 months. This study showed superior functional outcomes in patients with a DIACF when an anatomic reduction is achieved regardless of the injury severity

Tranexamic Acid (TXA) is widely used to decrease bleeding by its antifibrinolytic mechanism. Its use is widespread within orthopaedic surgery, with level one evidence for its efficacy in total hip and knee replacement surgery; significantly reducing transfusion rates without increased thromboembolic disease. There is limited evidence for its use during hip fracture surgery, and we therefore sought to investigate its effects with a prospective cohort study. We recorded intra-operative blood loss, pre and post-operative haemoglobin and creatinine levels, post-operative complications and mortality in all hip fracture patients over a six month period. During this time, we introduced one gram of TXA into our standardised hip fracture theatre checklist. It was subsequently given to all patients unless contra-indicated. A total of 99 patients were included. 90-day mortality in the control group was 16%, there was no mortality in the TXA group (p<0.05). 14 patients required a transfusion in the control group and 3 in the TXA group (19% vs 11% transfusion rate, 0.36 units RCC vs 0.22 per patient respectively) Mean blood loss was 338 vs 235mls, Haemoglobin drop 23 vs 18g/dl control and TXA groups respectively. We have demonstrated a significantly lower mortality rate with TXA. We have also shown lower rates of transfusion, blood loss and recorded haemoglobin drop with the use of TXA. We intend to continue this study to demonstrate this significantly, and fully clarify the safety profile of TXA in this frail cohort of patients

Introduction. Periprosthetic joint infection (PJI) is a serious problem and requires great effort and cost for its treatment. Treatment options may vary from resection arthroplasty, retention of prosthesis with debridement, one stage revision and two stage revision with handmade antibiotic impregnated cement spacer or with prefabricated antibiotic loaded cement spacer. Two stage revision remains the gold standard for the treatment of periprosthetic joint infection after Total Hip Arthroplasty (THA). This study was aimed to find the efficacy and cost effectiveness of handmade antibiotic impregnated articulating cement spacer over commercially available prefabricated antibiotic loaded cement spacer for the treatment of deep PJI of hip prosthesis and to evaluate its functional outcome. Material and methods. A total of 23 PJI patients were enrolled in this prospective cohort study. In the two stages of revision, the first stage consisted of thorough debridement, implant removal and implantation of handmade articulating antibiotic impregnated cement spacer. The second stage surgery consisted of removal of cement spacer, thorough debridement and implantation of new prosthesis. All patients were followed for a period of 24 months. Results. A total of 23 patients (15 males and 8 females) underwent two stage revision arthroplasty for chronic periprosthetic joint infection. The mean age of the patient was 57 years. The handmade antibiotic impregnated cement spacer was retained for 16– 20 weeks. Common organism observed was coagulase negative staphylococci followed by Staphylococcus aureus. After an average follow up of 2 years, 20 patients with PJI remained clinically free of infection. In 2 patients there was recurrence of infection. Conclusion. We conclude that two stage revision by hand made cement spacer is successful in eradication of infection with satisfactory functional outcome. Furthermore, these handmade cement spacer are cost effective and their efficacy may be comparable to commercially available prefabricated spacer

Aim. Current guidelines recommend the combination of vancomycin with either piperacillin-tazobactam (PT) or a third generation cephalosporin (3GC) as empirical antimicrobial therapy of PJI, immediately after surgery. However, clinical and biological safeties of such high dose-combinations are poorly known. Method. All patients managed in a reference center in France between 2011 and 2016 receiving an empirical antimicrobial therapy for PJI were included in a prospective cohort study. Antimicrobial-related AE upcoming during the empirical treatment phase were describe according to the Common Terminology Criteria for Adverse Events (CTCEA), and severe ones (grade ≥ 3) were reported to pharmacovigilance. AE determinants were assessed using univariate logistic regression. Results. Three hundred and thirty-one patients (166 males, 50.2%; median age, 70.1 (IQR, 59.4–79.1) years) with empirically-treated PJI were included. Vancomycin (n=228; 68.9%), teicoplanin (n=33; 10.0%), antistaphylococcal penicillin (n=29; 8.8%) and daptomycin (n=4; 1.2%) were the most commonly used anti-Gram positive antimicrobials. Most common combinations were vancomycin-PT (n=122;36.9%) and vancomycin-3GC (n=33; 10.0%). Forty-two (12.7%) patients experienced 49 AE in a median delay of 8 (IQR, 5–13) days. They included 25 acute kidney injuries (AKI; 7.6% of patients) including 16 (4.8%) without vancomycin overdose, 4 drug reactions with eosinophilia and systemic symptoms, isolated fevers, rashes or pruritus (1.2% each), 3 eosinophilia (0.9%), 2 hepatitis (0.6%), and one febrile neutropenia, injection site reaction or vomiting (0.3% each). Ten AE were considered as severe (3.0% of patients). Treatment has to be stopped in most cases (n=38; 95.0%). All AE had a favorable outcome. In univariate analysis, the use of vancomycin (OR 6.878; p=0.026) and/or PT (OR 3.667; p<10–3), and consequently the vancomycin-PT combination (OR 4.149; p<10–3) were found to be determinants of empirical antimicrobial therapy-related AE. Moreover, vancomycin-PT combination was found as an AKI risk-factor (OR 8.000; p<10–3). Conclusions. Empirical antimicrobial therapy of PJI is associated with a high rate of AE. These results reinforce recent data suggesting an increased risk of AKI when using vancomycin in combination with PT and encouraging the preferential use of 3GC or cefepim in this indication

Malnutrition is often associated with the advanced age and can be influenced by physical, mental, social and environmental changes. Hip fracture is a major issue and a prior poor nutritional status is associated with higher rates of perioperative complications and prolonged hospital length of stay. Prospective observational cohort study performed in a Level one trauma center including 189 consecutive patients admitted for hip fracture. The main outcome measure was the Mini Nutritional Assessment (MNA), a specific tool validated for geriatric population. This questionnaire was performed at admission by an independent assessor, at the same time as a large set of demographic and functional data. Blood samples were tested for blood count and albuminemia. Two groups were constituted and analysed according to a MNA score ≥ 24 (lower limit for normal nutritional status). Factors explored included physical and mental items. Impact of malnutrition was determined on hospital length of stay (HLS), discharge in an adverse location than prior to admission (DAL), complications and mortality rate. The rate of patients with malnutrition (or at risk) in this study is 47% (88 patients). Patients with a MNA < 24 are older (84.81 yrs ± 7.75 vs 80.41 ± 8.11, p<0,01), have more comorbidities (Charlson 2.8 ± 2.21 vs 1.67 ± 3.10, p<0,01), a more impaired mental (MMSE 19.39±8.55 vs 25.6±3.6, p<0,01) or physical status (MIF 105.3 ± 26.6 vs 121.8 ± 6.4, p< 0,01). Blood samples are not selective to detect malnutrition (p=0,64). Malnutrition is associated with a longer HLS (26.04±23.39 days vs 13.95±11.34 days, p<0,01), a greater DAL (58.9% vs 38.2%, p=0,02) and a higher one year mortality rate (23.9% vs 8.9 %, p<0,01). The prevalence of malnutrition in a geriatric population admitted for hip fracture is high. Blood samples at admission have clearly a poor value and a systematic screening with the MNA is mandatory. An early diagnosis will target specific interventions to reduce the physical and socio-economic impact of the malnutrition. Future studies should focus on actions in the perioperative stage (fast-track surgery, nutritional protocols, analgesia) and their impact on the socio-economic burden

Background. Periprosthetic joint infection (PJI) remains challenging as a “gold standard” for diagnosis has not yet been established. The aim of this study was to evaluate the accuracy of synovial fluid procalcitonin (SF-PCT) and serum procalcitonin as diagnostic biomarker for PJI and compared their accuracy with standard methods. Materials and Methods. A single-centered prospective cohort study was conducted between 2015–2017 in 32 patients with painful hip or knee arthroplasty underwent revision surgery. Relevant clinical and laboratory data were collected. PJI was diagnosed based on the 2013 international consensus criteria. Preoperative blood sample and intraoperatively acquired joint fluid were taken for PCT measurement with a standard assay. Diagnostic accuracy was analyzed by the receiver-operating characteristic (ROC) curve and the area under the curve (AUC). Results. Twenty patients (62.5%) were classified as PJI, and 12 of them (37.5%) were classified as aseptic loosening group. The median age was 68 years (range 38–87 years). The median values of SF-PCT and serum PCT in PJI group were both significant higher than those in aseptic loosening group: the median serum PCT levels (interquartile range: IQR) were 0.33 ng/mL (0.08–2.79 ng/mL) in PJI group compared with 0.04 ng/mL (0.03–0.06 ng/mL), and the median SF-PCT levels (IQR) were 0.16 ng/mL (0.12–0.26 ng/mL) in PJI group compared with 0.00 (0.00–0.00 ng/mL) (p<0.001 both) (Fig 1). SF-PCT, with a cut-off level as 0.08 ng/mL, had a AUC of 0.87, a sensitivity of 90.0% and a specificity of 83.3%, and a negative likelihood ratio (LR-) of 0.12. Whereas serum PCT, with a standard cut-off level as 0.5 ng/mL, had a AUC of 0.70, a sensitivity of 40.0% and a specificity of 100.0%, and a LR- of 0.60. (Fig 2–3). Conclusion. SF-PCT appears to be a reliable test and could be useful as an alternative indicator or in combination for the diagnosis of PJI

Introduction and Objective. Hip fractures represent one of the most challenging injuries in orthopaedic practice due to the associated morbidity, mortality and the financial burden they impose on the health care systems. By many still considered as the gold standard in the management of intertrochanteric fractures, the Dynamic Hip Screw utilizes controlled collapse during weight bearing to stabilize the fracture. Despite being a highly successful device, mechanical failure rate is not uncommon. The most accepted intraoperative indicator for lag screw failure is the tip apex distance (TAD), yet lateral femoral wall thickness (LWT) is another evolving parameter for detecting the potential for lateral wall fracture with subsequent medialization and implant failure. The aim of this study is to determine the mean and cut off levels for LWT that warrant lateral wall fracture and the implications of that on implant failure, revision rates and implant choice. Materials and Methods. This prospective cohort study included 42 patients with a mean age of 70.43y with intertrochanteric hip fractures treated with DHS fixation by the same consultant surgeon from April 2019 to December 2019. The study sample was calculated based on a confidence level of 90% and margin of error of 5%. Fracture types included in the study are 31A1 and 31A2 based on the AO/OTA classification system. LWT was assessed in all patients preoperatively using Surgimap (Nemaris, NY, USA) software. Patients were divided into two groups according to the post-operative integrity of the lateral femoral wall, where group (A) sustained a lateral femoral wall fracture intraoperatively or within 12 months after the index procedure, while in group (B) the lateral femoral wall remained intact. All patients were regularly followed up radiologically and clinically per the Harris Hip Score (HHS) for a period of 12 months. Results. At 12 months five patients (12%) suffered a postoperative lateral wall fracture, while in 37 patients (88%) the lateral femoral wall remained intact. The mean preoperative LWT of patients with a postoperative lateral wall fracture was 18.04 mm (SD ± 1.58) compared to 26.22mm (SD ± 5.93) in the group without a lateral wall fracture. All patients with post-operative lateral femoral wall fracture belong to 31A2 group, while 78.4% of the patients that did not develop post-operative lateral femoral wall fracture belong to 31A1 group. Eighty percent of patients in group (A) experienced shortening, collapse, shaft medialization and varus deformity. The mean Harris hip score of group (A) was 39.60 at 3 months and 65.67 at 6 months postoperatively, while that of group (B) was 80.75 and 90.65 at 3 and 6 months respectively, denoting a statistically significant difference (P<0.001). Treatment failure meriting a revision surgery was 40 % in group (A) and 8% in group (B) denoting a statistically significant difference (p<0.001). The cut-off point of LWT below which there is a high chance of post-operative lateral wall fracture when fixed with DHS is 19.6mm. This was shown on the receiver operating curve (ROC) by plotting the sensitivity against the 100 % specificity with a set 95% confidence interval 0.721 – 0.954. When lateral wall thickness was at 19.6 mm, the sensitivity was 100% and specificity was 81.8%. The area under the curve (AUC) was 0.838, which was statistically significant (P = 0.015). Conclusions. Preoperative measurement of LWT in elderly patients with intertrochanteric hip fractures is decisive. The cut off point for postoperative lateral wall fracture according to our study is 19.6 mm; hence, intramedullary fixation has to be considered in this situation

Introduction

Recent technological advancements have led to the introduction of robotic-assisted total knee arthroplasty to improve the accuracy and precision of bony resections and implant position. However, the in vivo accuracy is not widely reported. The primary objective of this study is to determine the accuracy and precision of a cut block positioning robotic arm.

Previously ankylosed or surgically arthrodesed hip joints can be converted successfully to a total hip replacement (THR) in order to improve patient mobility and function. We present a long term prospective cohort study of cementless revisions of previously ankylosed hips. Sixteen hips (15 patients) with a mean age of 52 years (range 16 to 75) had ankylosed hips for a mean of 36 years (range 3.5 to 65 years). They all received a cementless THR between August 1988 and January 2003 and were prospectively followed-up for a mean of 11 years (range 5.0 to 19 years). Two patients died during the study period of unrelated causes and none were lost to follow-up. All patients showed improved mobility and function following the conversion of their ankylosed hips. The Harris Hip Score improved from a pre-operative mean value of 70 (Standard Error of Mean (SEM) 3.4) to a post-operative value of 83 (SEM 4.4) at the latest review, which was statistically significant (p < 0.05). There was one acetabular cup revision at 5 years post implantation for aseptic loosening. At a mean of 11 years post THR, all other femoral and acetabular components remained clinically and radiographically well fixed. One patient with systemic ankylosing spondylitis and spontaneous bilateral bony hip ankylosis developed the unusual complication of Paget’s disease of the left hemipelvis and proximal femur two years after successful bilateral THR surgery. His symptoms resolved following medical therapy for Paget’s disease. We conclude that a previously ankylosed hip can be effectively converted to a cementless total hip replacement with good long term results

Summary Statement. Service industry metrics (the net promoter score) are being introduced as a measure of UK healthcare satisfaction. Lower limb arthroplasty, as a ‘service’, scores comparably with the most successful commercial organisations. Background. Satisfaction with care is important to both the patient and the payer. The Net Promoter Score, widely used in the service industry, has been recently introduced to the UK National Health Service as an overarching metric of patient satisfaction and to monitor performance. This questionnaire asks ‘customers’ if they would recommend a service or products to others. Scores range from −100 (everyone is a detractor) to +100 (everyone is a promoter). In industry, a positive score is well regarded, with those over 50 regarded as excellent. Our aims were to assess net promoter scores for joint arthroplasty, to compare these scores with direct measures of patient satisfaction, and to evaluate which factors contributed to net promoter response. Methods. 6912 individuals undergoing primary lower limb joint replacement over a five year period (Jan 2007 – Dec 2011) took part in a prospective cohort study at a single NHS University hospital. Net promoter score, clinical outcomes as measured by PROMS (Oxford Hip or Knee Score and SF-12 score), multi-faceted patient satisfaction questionnaire, demographic data and length of hospital stay were recorded. Data was collected preoperatively and at 1 year post-surgery. Multivariate regression was performed to determine which factors could predict an outcome of ‘promoter’ and ‘detractor’ at 1 year post-surgery. Significance was accepted at p = 0.1 to accommodate the confounding effect of other variables. Results. Net promoter scores for knee and hip replacements were 49 and 71 respectively. Strong correlation was seen between overall satisfaction and whether the patient would recommend the operation to another (r = 0.637), though regression of these factors was modest (R. 2. = 0.406). Only 4 factors were relevant to the net promoter response: pain relief (OR 2.13, CI 1.83 – 2.49), meeting expectations (OR 2.57, CI 2.24 – 2.97), hospital experience (OR 2.33, CI 2.03 – 2.68) and arthroplasty type (OR 2.31, CI 1.68 – 3.17). These factors drove a model able to explain 95% of the variation in net promoter score. Conclusions. This is the first analysis of net promoter score for joint arthroplasty, and demonstrates values that compare favourably with the services provided by the most successful commercial organizations. The UK Department of Health describes this score as a measure of patient satisfaction. This is perhaps not completely accurate, as only a third of the variation in one response can be explained by the other, suggesting that although clearly related, these concepts are not the same. Pain relief, meeting of expectations of surgery, the hospital experience and whether the hip or knee joint is replaced are the only relevant factors in determining the net promoter response. Factors thought to influence clinical outcome such as depression, number of comorbidities, age and gender carry no influence with this metric

Purpose: Comorbidities in patients undergoing total joint arthroplasty continue to be a challenging problem. Retrospective studies have demonstrated that co-morbidities affect outcomes of revision total knee arthroplasty (RTKA). However, the relationship between the outcomes of RTKA and co-morbidities has not been well established. This prospective randomized study was undertaken to investigate these relationships. Method: A prospective cohort study (the North America Knee Arthroplasty Revision Study) was conducted to examine factors that predict outcomes after RTKA. 308 subjects met inclusion/exclusion criteria. Subjects were followed from the time of the index surgery for a minimum of two years to monitor outcomes and complications. Validated quality of life instruments, including SF-36, WOMAC, Knee Society Score, and an activity scale were used. The rates of improvement from 0 to 12 and 12 to 24 months were analyzed. Results: There were 145 males and 163 females. The mean age was 68.7 years. Mean time from primary procedure to RTKA was 7.9 years. Arthroplasty failure was classified as aseptic in 82% and septic in 18% of the cases. Hypertension was seen in 62.4%, back pain in 50%, heart disease in 25.9%, diabetes mellitus in 23.9%, gastric ulcers in 17.9%, and rheumatoid arthritis in 16.6%. Less frequent co-morbidities included anemia, cancer, kidney disease, lung disease and liver disease. Conclusion: Analyses showed that the number of reported co-morbidities was the most significant predictor of outcomes, consistently forecasting poorer functional improvement on all measures. The results indicated that ultimate treatment of co-morbidities before and after surgery may improve outcomes of RTKA. Comorbidities in patients undergoing revision TKA can be a challenging problem. This study showed that the number of reported co-morbidities was the most significant predictor of poorer outcomes

The use of total hip arthroplasty in adolescents for end-stage degenerative hip disease is controversial with few reported outcomes in the literature. The purpose of the study was to report the outcomes of total hip arthroplasty in a cohort of adolescents managed by a multidisciplinary team of paediatric and adult orthopaedic surgeons from a single centre.

A multidisciplinary clinic consisting of paediatric and adult hip surgeons was established in 2013 to identify, treat and prospectively follow adolescents who would potentially beneift from a total hip arthoplasty. To date 29 consecutive adolescent patients (20 female, 9 male, 32 hips) with end stage degenerative hip disease have undergone cementless primary total hip arthroplasty. Mean age at decision to treat was 15.7 years (age 11.4–18.5). Ten different underlying paediatric specific pathologies were documented including DDH, cerebral palsy, JIA, skeletal dysplasias, SCFE and idiopathic chondrolysis. Three patients had bilateral staged procedures. Clinical baseline and outcomes were measured using Oxford Hip Score (OHS), WOMAC score and ASKp scores. Radiographic follow-up was conducted at 6 weeks, 6 months and yearly thereafter. Post-operative complications were recorded.

Twenty-five hips were eligible for minimum 2-year follow-up scoring at a mean 2.7 years (2.0–3.6 years). No intraoperative complications occurred. One case of recalcitrant postoperative psoas tendonitis occured. OHS improved from 25 (7–43) to 41 (23–48). WOMAC improved from 48 (12–8) to 12 (1–44), and ASKp improved from 78% (33–98%) to 93% (73–100%). Radiographic review revealed acceptable alignment of all components with no signs of loosening or wear. No revision of components was required. One patient died at 6 months post op from an unrelated condition.

The early term results of total hip arthroplasty in adolescents from our multidisciplinary program are encouraging. Improvements in quality of life to normal values were seen as were hip scores consistent with satisfactory joint function. Depite the range of complex and varied causes of arthritis seen in this population the establishment of combined paediatric and adult orthopaedic surgical teams appears to be a successful model to manage end-stage degenerative hip disease in adolescents.

Study purpose: Cancer patients presenting with symptomatic spinal metastases is an increasing problem. It is widely accepted that surgery plays an important role in the management of these patients and recent studies1 conclude that surgical treatment should be more frequently offered. However, who should be offered surgery remains controversial, largely because of a lack of information about outcome. Our study is a prospective analysis of survival and functional outcome in patients with metastatic spinal disease treated primarily by surgical decompression and stabilisation when indicated. Methods: Sixty two patients with radiologically suspected metastatic spinal disease, managed by one consultant neurosurgeon, were enrolled into a prospective cohort study. Patients presented with pain and or myelopathy. Survival, continence, walking, analogue pain scores and short form 36 (SF-36) scores were analysed. Results: Median age was 62 years (22–79 years, 35 female, 27 male) with the commonest primary tumours being breast (26%), lymphoma (13%) and prostate (10%). Lung cancer was poorly represented (1 patient). Survival rates were 56% at 1 year, 49% at 2 years and 28% at 3 years. Of 16 patients not walking pre-op, 8 gained the ability to walk, while 5 out of 7 incontinent patients gained continence following surgery. Conclusion: Our data indicate that long term survival and favourable functional outcomes can be achieved following surgery in patients with metastatic spinal disease. We strongly advocate that patients presenting with metastatic spinal disease be considered for primary surgical treatment but would highlight the importance of appropriate patient selection

Abstract

Background

Low back pain can lead to neuroplastic changes in the central nervous system, known as nociplastic pain. As nociplastic pain may be provoked by premorbid sensory profiles, such profiles may be prognostic in the development of nociplastic pain over time.

Robotic assisted surgery aims to reduce surgical errors in implant positioning and better restore native hip biomechanics compared to conventional techniques for total hip arthroplasty (THA). The primary objective of this study was to compare accuracy in restoring the native centre of hip rotation in patients undergoing conventional manual THA versus robotic-arm assisted THA. Secondary objectives were to determine differences between these treatment techniques for THA in achieving the planned combined offset, cup inclination, cup version, and leg-length correction. This prospective cohort study included 50 patients undergoing conventional manual THA and 25 patients receiving robotic-arm assisted THA. All operative procedures were undertaken by a single surgeon using the minimally-invasive posterior approach. Two independent blinded observers recoded all radiological outcomes of interest using plain radiographs. Patients in both treatment groups were well-matched for age, gender, body mass index, laterality of surgery, and ASA scores. Interclass correlation coefficient was 0.92 (95% CI: 0.84 – 0.95) for intra-observer agreement and 0.88 (95% CI: 0.82–0.94) for inter-observer agreement in all study outcomes. Robotic THA was associated with improved accuracy in restoring the native horizontal (p<0.001) and vertical (p<0.001) centres of rotation, and improved preservation of the patient's native combined offset (P<0.001) compared to conventional THA. Robotic THA improved accuracy in positioning of the acetabular cup within the combined safe zones of inclination and anteversion described by Lewinnek et al (p=0.02) and Callanan et al (p=0.01) compared to conventional THA (figures 1–2). There was no difference between the two treatment groups in achieving the planned leg-length correction (p=0.10). Robotic-arm assisted THA was associated with improved accuracy in restoring the native centre of rotation, better preservation of the combined offset, and more precise acetabular cup positioning within the safe zones of inclination and anteversion compared to conventional manual THA. Robotic-arm assisted THA enables improved preservation of native hip biomechanics compared to conventional manual THA. For any figures or tables, please contact authors directly: . fsh@fareshaddad.net

Aims

This study sought to determine the proportion of older adults with hip fractures captured by a multicentre prospective cohort, the World Hip Trauma Evaluation (WHiTE), whether there was evidence of selection bias during WHiTE recruitment, and the extent to which the WHiTE cohort is representative of the broader population of older adults with hip fractures.

Aims: To explore potential predictors of functional outcome one year after the injury in elderly women who sustained a displaced intracapsular hip fracture and who were treated with internal fixation, hemiarthroplasty, or total hip arthroplasty. Methods: Eighty-four women aged > 50 years were enrolled on a consecutive basis in this one-year prospective cohort study reflecting standard day-to-day clinical practice. The main outcome measure was the Rapid Disability Rating Scale version-2 applied at hospital discharge and one year later. Results: The total hip arthroplasty group was younger (p< 0.001) and had a better functional status than the internal fixation or hemiarthroplasty groups (p< 0.001) at hospital discharge. One year later, the best function was still observed in the total arthroplasty group, but the differences were small and failed to achieve the level of statistical significance. During that one-year period, walking ability or mobility did not change significantly after total hip arthroplasty, but a significant proportion of the women developed cognitive impairment, including mental confusion, uncooperativeness, and depression (p< 0.001). Overall, the most significant predictors of poor functional status one year after fracture were increasing age (p=0.005), living in an institution at time of injury (p=0.034), and poor functional status at discharge (p< 0.001). Conclusions: In elderly women with a displaced intra-capsular hip fracture, total hip arthroplasty is associated with a functional benefit within the first months after surgery. However, the extent to which this functional benefit is maintained over time, is less clear. Our results support the need for randomised clinical trials among elderly women with a displaced intracapsular hip fracture to quantify the extent to which the early functional benefit of total hip arthroplasty is maintained in the long run or compromised by progressive cognitive impairment and other negative determinants of functional outcome

Introduction: Lumbar spinal stenosis commonly affects elderly patients with multiple co-morbidities. They are at increased risk of complications following surgical interventions. Non-operative strategies for treating them are desirable and previous studies have shown some benefit of subcutaneous salmon calcitonin for the treatment of spinal stenosis. Objectives: To assess the effectiveness of nasal salmon calcitonin for the treatment of lumbar spinal stenosis in a cohort of patients. Study design: Prospective cohort study. Methods: 34 patients with MRI proven lumbar spinal stenosis were enrolled into the trial. They received salmon calcitonin in the form of a nasal spray for 6 weeks. All the patients had multiple co-morbidities making them high risk for any surgical intervention. They were followed up at 6 weeks and at 12 weeks. The main outcome measures were oswestry disability index (ODI), low back outcome score (LBOS) and visual analogue scale (VAS). The patient’s were also subjectively asked to rate the treatment excellent, good, fair or poor. Results: The mean age was 73.5 years (range 51–92 years). The mean duration of symptoms was 32.6 months (range 3–120 months) The mean ODI pre-treatment was 50 and after 6 weeks of treatment decreased to 47 (p=0.14). The mean LBOS was 18 pre-treatment and increased to 21 (p=0.02) after 6 weeks of treatment. The mean VAS for leg pain was 76mm pre-treatment and decreased to 64mm (p=0.001) after treatment and the mean VAS for back pain only decreased from 64mm to 61mm (p=0.5). 11 patients (32%) had a minimum 20mm change in VAS scores after treatment and 7 patients (21%) improved their ODI score by a minimum of 10 points. All results remained stable at 12 weeks follow-up, suggesting a longer effect than the duration of treatment. With regards to patient’s subjective outcome 9 patients (27%) rated the treatment as fair, 3 rated it as good (9%) and 17 reported no change (50%). Conclusion: Our results suggest the benefits of nasal salmon calcitonin treatment are marginal, with a minimal improvement in symptoms of patients with lumbar spinal stenosis