This study describes the epidemiology and outcome
of 637 proximal humeral fractures in 629 elderly (≥ 65 years old) patients.
Most were either minimally displaced (n = 278, 44%) or two-part
fractures (n = 250, 39%) that predominantly occurred in women (n
= 525, 82%) after a simple fall (n = 604, 95%), who lived independently
in their own home (n = 560, 88%), and one in ten sustained a concomitant
fracture (n = 76, 11.9%). The rate of mortality at one year was
10%, with the only independent predictor of survival being whether
the patient lived in their own home (p = 0.025). Many factors associated
with the patient’s social independence significantly influenced
the age and gender adjusted Constant score one year after the fracture.
More than a quarter of the patients had a poor functional outcome,
with those patients not living in their own home (p = 0.04), participating
in recreational activities (p = 0.01), able to perform their own
shopping (p <
0.001), or able to dress themselves (p = 0.02)
being at a significantly increased risk of a poor outcome, which
was independent of the severity of the fracture (p = 0.001). A poor functional outcome after a proximal humeral fracture is
not independently influenced by age in the elderly, and factors
associated with social independence are more predictive of outcome. Cite this article:
Satisfaction with care is important to both patients
and to those who pay for it. The Net Promoter Score (NPS), widely
used in the service industries, has been introduced into the NHS
as the ‘friends and family test’; an overarching measure of patient
satisfaction. It assesses the likelihood of the patient recommending
the healthcare received to another, and is seen as a discriminator
of healthcare performance. We prospectively assessed 6186 individuals
undergoing primary lower limb joint replacement at a single university
hospital to determine the Net Promoter Score for joint replacements
and to evaluate which factors contributed to the response. Achieving pain relief (odds ratio (OR) 2.13, confidence interval
(CI) 1.83 to 2.49), the meeting of pre-operative expectation (OR
2.57, CI 2.24 to 2.97), and the hospital experience (OR 2.33, CI
2.03 to 2.68) are the domains that explain whether a patient would
recommend joint replacement services. These three factors, combined
with the type of surgery undertaken (OR 2.31, CI 1.68 to 3.17),
drove a predictive model that was able to explain 95% of the variation
in the patient’s recommendation response. Though intuitively similar,
this ‘recommendation’ metric was found to be materially different
to satisfaction responses. The difference between THR (NPS 71) and
TKR (NPS 49) suggests that no overarching score for a department
should be used without an adjustment for case mix. However, the
Net Promoter Score does measure a further important dimension to
our existing metrics: the patient experience of healthcare delivery. Cite this article:
Satisfaction is increasingly employed as an outcome
measure for a successful total knee replacement (TKR). Satisfaction
as an outcome measure encompasses many different intrinsic and extrinsic
factors related to a person’s experience before and after TKR. The
Swedish Knee Arthroplasty Registry has previously demonstrated on
a large population study that 17% of TKR recipients are not satisfied
with their TKR outcome. This finding has been replicated in other
countries. Similar significant factors emerged from these registry
studies that are related to satisfaction. It would appear that satisfaction
is better after more chronic diseases and whether the TKR results
in pain relief or improved function. Importantly, unmet pre-operative
expectations are a significant predictor for dissatisfaction following
a TKR. It may be possible to improve rates by addressing the issues
surrounding pain, function and expectation before embarking on surgery. Cite this article:
The December 2013 Knee Roundup360 looks at: Conflict of interest and hyaluronic acid; Will time indeed tell in microfracture?; Contralateral knee pain and joint replacement outcomes; Patient satisfaction and knee replacement?; Hope in the cytokines for painful TKRs?; Pain severity, cytokines and osteoarthritis?; Quadriceps weakness and pain; and spontaneous osteonecrosis of the knee
The December 2013 Hip &
Pelvis Roundup360 looks at: Enhanced recovery works; Acetabular placement; Exercise better than rest in osteoarthritis patients; if Birmingham hip resurfacing is immune from pseudotumour; HIV and arthroplasty; Labral tears revisited; Prophylactic surgery for FAI; and Ceramics and impaction grafting
Using the Trent regional arthroplasty register, we analysed the survival at ten years of 1198 consecutive Charnley total hip replacements carried out across a single health region of the United Kingdom in 1990. At ten years, information regarding outcome was available for 1001 hips (83.6%). The crude revision rate was 6.2% (62 of 1001) and the cumulative survival rate with revision of the components as an end-point was 93.1%. At five years, a review of this series of patients identified gross radiological failure in 25 total hip replacements which had previously been unrecognised. At ten years the outcome was known for 18 of these 25 patients (72%), of whom 13 had not undergone revision. This is the first study to assess the survival at ten years for the primary Charnley total hip replacement performed in a broad cross-section of hospitals in the United Kingdom, as opposed to specialist centres. Our results highlight the importance of the arthroplasty register in identifying the long-term outcome of hip prostheses.
The October 2013 Oncology Roundup360 looks at:
The purposes of this study were to define the range of laxity of the interosseous ligaments in cadaveric wrists and to determine whether this correlated with age, the morphology of the lunate, the scapholunate (SL) gap or the SL angle. We evaluated 83 fresh-frozen cadaveric wrists and recorded the SL gap and SL angle. Standard arthroscopy of the wrist was then performed and the grades of laxity of the scapholunate interosseous ligament (SLIL) and the lunotriquetral interosseous ligament (LTIL) and the morphology of the lunate were recorded. Arthroscopic evaluation of the SLIL revealed four (5%) grade I specimens, 28 (34%) grade II, 40 (48%) grade III and 11 (13%) grade IV. Evaluation of the LTIL showed 17 (20%) grade I specimens, 40 (48%) grade II, 28 (30%) grade III and one (1%) grade IV. On both bivariate and multivariate analysis, the grade of both the SLIL and LTIL increased with age, but decreased with female gender. The grades of SLIL or LTIL did not correlate with the morphology of the lunate, the SL gap or the SL angle. The physiological range of laxity at the SL and lunotriquetral joints is wider than originally described. The intercarpal ligaments demonstrate an age-related progression of laxity of the SL and lunotriquetral joints. There is no correlation between the grades of laxity of the SLIL or LTIL and the morphology of the lunate, the SL gap or the SL grade. Based on our results, we believe that the Geissler classification has a role in describing intercarpal laxity, but if used alone it cannot adequately diagnose pathological instability. We suggest a modified classification with a mechanism that may distinguish physiological laxity from pathological instability.
We performed a case–control study to compare
the rates of further surgery, revision and complications, operating time
and survival in patients who were treated with either an uncemented
hydroxyapatite-coated Corail bipolar femoral stem or a cemented
Exeter stem for a displaced intracapsular fracture of the hip. The
mean age of the patients in the uncemented group was 82.5 years
(53 to 97) and in the cemented group was 82.7 years (51 to 99) We used
propensity score matching, adjusting for age, gender and the presence
or absence of dementia and comorbidities, to produce a matched cohort
receiving an Exeter stem (n = 69) with which to compare the outcome of
patients receiving a Corail stem (n = 69). The Corail had a significantly
lower all-cause rate of further surgery (p = 0.016; odds ratio (OR)
0.18, 95% CI 0.04 to 0.84) and number of hips undergoing major further
surgery (p = 0.029; OR 0.13, 95% CI 0.01 to 1.09). The mean operating
time was significantly less for the Corail group than for the cemented Exeter
group (59 min [12 to 136] Cite this article:
This study reports the mid-term results of a large-bearing hybrid metal-on-metal total hip replacement in 199 hips (185 patients) with a mean follow-up of 62 months (32 to 83). Two patients died of unrelated causes and 13 were lost to follow-up. In all, 17 hips (8.5%) have undergone revision, and a further 14 are awaiting surgery. All revisions were symptomatic. Of the revision cases, 14 hips showed evidence of adverse reactions to metal debris. The patients revised or awaiting revision had significantly higher whole blood cobalt ion levels (p = 0.001), but no significant difference in acetabular component size or position compared with the unrevised patients. Wear analysis (n = 5) showed increased wear at the trunnion-head interface, normal levels of wear at the articulating surfaces and evidence of corrosion on the surface of the stem. The cumulative survival rate, with revision for any reason, was 92.4% (95% confidence interval 87.4 to 95.4) at five years. Including those awaiting surgery, the revision rate would be 15.1% with a cumulative survival at five years of 89.6% (95% confidence interval 83.9 to 93.4). This hybrid metal-on-metal total hip replacement series has shown an unacceptably high rate of failure, with evidence of high wear at the trunnion-head interface and passive corrosion of the stem surface. This raises concerns about the use of large heads on conventional 12/14 tapers.
Fractures of the proximal femur are one of the
greatest challenges facing the medical community, constituting a
heavy socioeconomic burden worldwide. Controversy exists regarding
the optimal treatment for patients with unstable trochanteric proximal
femoral fractures. The recognised treatment alternatives are extramedullary
fixation usually with a sliding hip screw and intramedullary fixation
with a cephalomedullary nail. Current evidence suggests that best
results and lowest complication rates occur using a sliding hip screw.
Complications in these difficult fractures are relatively common
regardless of type of treatment. We believe that a novel device,
the X-Bolt dynamic plating system, may offer superior fixation over
a sliding hip screw with lower reoperation risk and better function.
We therefore propose to investigate the clinical effectiveness of
the X-bolt dynamic plating system compared with standard sliding
hip screw fixation within the framework of a the larger WHiTE (Warwick
Hip Trauma Evaluation) Comprehensive Cohort Study. Cite this article:
We investigated the role of ion release in the assessment of fixation of the implant after total knee replacement and hypothesised that ion monitoring could be a useful parameter in the diagnosis of prosthetic loosening. We enrolled 59 patients with unilateral procedures and measured their serum aluminium, titanium, chromium and cobalt ion levels, blinded to the clinical and radiological outcome which was considered to be the reference standard. The cut-off levels for detection of the ions were obtained by measuring the levels in 41 healthy blood donors who had no implants. Based on the clinical and radiological evaluation the patients were divided into two groups with either stable (n = 24) or loosened (n = 35) implants. A significant increase in the mean level of Cr ions was seen in the group with failed implants (p = 0.001). The diagnostic accuracy was 71% providing strong evidence of failure when the level of Cr ions exceeded the cut-off value. The possibility of distinguishing loosening from other causes of failure was demonstrated by the higher diagnostic accuracy of 83%, when considering only patients with failure attributable to loosening. Measurement of the serum level of Cr ions may be of value for detecting failure due to loosening when the diagnosis is in doubt. The other metal ions studies did not have any diagnostic value.
Despite the increasing prevalence of sleep apnoea,
little information is available regarding its impact on the peri-operative
outcome of patients undergoing posterior lumbar fusion. Using a
national database, patients who underwent lumbar fusion between
2006 and 2010 were identified, sub-grouped by diagnosis of sleep
apnoea and compared. The impact of sleep apnoea on various outcome
measures was assessed by regression analysis. The records of 84
655 patients undergoing posterior lumbar fusion were identified
and 7.28% (n = 6163) also had a diagnostic code for sleep apnoea.
Compared with patients without sleep apnoea, these patients were
older, more frequently female, had a higher comorbidity burden and
higher rates of peri-operative complications, post-operative mechanical
ventilation, blood product transfusion and intensive care. Patients
with sleep apnoea also had longer and more costly periods of hospitalisation. In the regression analysis, sleep apnoea emerged as an independent
risk factor for the development of peri-operative complications
(odds ratio (OR) 1.50, confidence interval (CI) 1.38;1.62), blood
product transfusions (OR 1.12, CI 1.03;1.23), mechanical ventilation
(OR 6.97, CI 5.90;8.23), critical care services (OR 1.86, CI 1.71;2.03), prolonged
hospitalisation and increased cost (OR 1.28, CI 1.19;1.37; OR 1.10,
CI 1.03;1.18). Patients with sleep apnoea who undergo posterior lumbar fusion
pose significant challenges to clinicians. Cite this article:
The August 2013 Foot &
Ankle Roundup360 looks at: mobility, ankles and fractures; hindfoot nailing: not such a bad option after all?; little treatment benefit for blood injection in tendonitis; fixed bearing ankles successful in the short term; hindfoot motion following STAR ankle replacement; minimally invasive calcaneal fracture fixation?; pes planus in adolescents; and subluxing peroneals and groove deepening
The August 2013 Children’s orthopaedics Roundup360 looks at: a multilevel approach to equinus gait; whether screening leads to needless intervention; salvage of subcapital slipped epiphysis; growing prostheses for children’s oncology; flexible nailing revisited; ultrasound and the pink pulseless hand; and slipping forearm fractures.
The June 2013 Research Roundup360 looks at: a contact patch to rim distance and metal ions; the matrix of hypoxic cartilage; CT assessment of early fracture healing; Hawthornes and radiographs; cardiovascular mortality and fragility fractures; and muscle strength decline preceding OA changes.
We evaluated radiological hip remodelling after shelf acetabuloplasty and sought to identify prognostic factors in 25 patients with a mean age of 8.9 years (7.0 to 12.3) who had unilateral Perthes’ disease with reducible subluxation of the hip in the fragmentation stage. At a mean follow-up of 6.7 years (3.2 to 9.0), satisfactory remodelling was observed in 18 hips (72%). The type of labrum in hip abduction, as determined by intra-operative dynamic arthrography, was found to be a statistically significant prognostic factor (p = 0.012). Shelf acetabuloplasty as containment surgery seems to be best indicated for hips in which there is not marked collapse of the epiphysis and in which the extruded epiphyseal segment slips easily underneath the labrum on abduction, without imposing undue pressure on the lateral edge of the acetabulum.
A nationwide study of Perthes’ disease in Norway was undertaken over a five-year period from January 1996. There were 425 patients registered, which represents a mean annual incidence of 9.2 per 100 000 in subjects under 15 years of age, and an occurrence rate of 1:714 for the country as a whole. There were marked regional variations. The lowest incidence was found in the northern region (5.4 per 100 000 per year) and the highest in the central and western regions (10.8 and 11.3 per 100 000 per year, respectively). There was a trend towards a higher incidence in urban (9.5 per 100 000 per year) compared with rural areas (8.9 per 100 000 per year). The mean age at onset was 5.8 years (1.3 to 15.2) and the male:female ratio was 3.3:1. We compared 402 patients with a matched control group of non-affected children (n = 1 025 952) from the Norwegian Medical Birth Registry and analysed maternal data (age at delivery, parity, duration of pregnancy), birth length and weight, birth presentation, head circumference, ponderal index and the presence of congenital anomalies. Children with Perthes’ disease were significantly shorter at birth and had an increased frequency of congenital anomalies. Applying Sartwell’s log-normal model of incubation periods to the distribution of age at onset of Perthes’ disease showed a good fit to the log-normal curve. Our findings point toward a single cause, either genetic or environmental, acting prenatally in the aetiology of Perthes’ disease.
In our department we use an enhanced recovery
protocol for joint replacement of the lower limb. This incorporates the
use of intravenous tranexamic acid (IVTA; 15 mg/kg) at the induction
of anaesthesia. Recently there was a national shortage of IVTA for
18 weeks; during this period all patients received an oral preparation
of tranexamic acid (OTA; 25 mg/kg). This retrospective study compares
the safety (surgical and medical complications) and efficacy (reduction
of transfusion requirements) of OTA and IVTA. During the study period
a total of 2698 patients received IVTA and 302 received OTA. After
adjusting for a range of patient and surgical factors, the odds
ratio (OR) of receiving a blood transfusion was significantly higher
with IVTA than with OTA (OR 0.48 (95% confidence interval 0.26 to
0.89), p = 0.019), whereas the safety profile was similar, based
on length of stay, rate of readmission, return to theatre, deep
infection, stroke, gastrointestinal bleeding, myocardial infarction,
pneumonia, deep-vein thrombosis and pulmonary embolism. The financial
benefit of OTA is £2.04 for a 70 kg patient; this is amplified when
the cost saving associated with significantly fewer blood transfusions
is considered. Although the number of patients in the study is modest, this
work supports the use of OTA, and we recommend that a randomised
trial be undertaken to compare the different methods of administering
tranexamic acid. Cite this article:
We evaluated the cost and consequences of proximal femoral fractures requiring further surgery because of complications. The data were collected prospectively in a standard manner from all patients with a proximal femoral fracture presenting to the trauma unit at the John Radcliffe Hospital over a five-year period. The total cost of treatment for each patient was calculated by separating it into its various components. The risk factors for the complications that arose, the location of their discharge and the mortality rates for these patients were compared to those of a matched control group. There were 2360 proximal femoral fractures in 2257 patients, of which 144 (6.1%) required further surgery. The mean cost of treatment in patients with complications was £18 709 (£2606.30 to £60.827.10), compared with £8610 (£918.54 to £45 601.30) for uncomplicated cases (p <
0.01), with a mean length of stay of 62.8 (44.5 to 79.3) and 32.7 (23.8 to 35.0) days, respectively. The probability of mortality after one month in these cases was significantly higher than in the control group, with a mean survival of 209 days, compared with 496 days for the controls. Patients with complications were statistically less likely to return to their own home (p <
0.01). Greater awareness and understanding are required to minimise the complications of proximal femoral fractures and consequently their cost.