John E. Lawrence

Do Patients Taking Warfarin Experience Delays to Theatre, Longer Hospital Stay, and Poorer Survival After Hip Fracture?

BackgroundPatients sustaining a fractured neck of the femur are typically of advanced age with multiple comorbidities. As a consequence, the proportion of these patients receiving warfarin therapy is approximately 10%. There are currently few studies investigating outcomes in this subset of patients.Questions/purposesThe purpose of this study was to assess the association between warfarin therapy and time to surgery, length of hospital stay, and survival in patients sustaining a fractured neck of the femur.MethodsData for 2036 patients admitted to our center between July 2009 and July 2014 with a fractured neck of the femur were extracted from the National Hip Fracture Database. Fifty-seven patients received no surgical treatment and were excluded from analysis. Multivariable ordinary least squares regression was performed to test the association between warfarin treatment on time to surgery and length of stay, and Cox proportional hazards to test followup survival. Variables included in the regression model were age, sex, American Society of Anesthesiologists (ASA) score, admission Abbreviated Mental Test Score (AMTS), fracture type, operation type, and premorbid Work Ability Index (WAI). One hundred fifty-two of 1979 surgically treated patients (8%) were receiving warfarin therapy at the time of admission.ResultsAfter controlling for age, sex, ASA score, AMTS, fracture type, operation type, and WAI, we found that patients taking warfarin were less likely to go to surgery by 36 hours (odds ratio [OR], 0.20; 95% CI, 0.14–0.30), and less likely to go to surgery by 48 hours (OR, 0.17; 95% CI, 0.11–0.24). Patients taking warfarin had a longer length of stay (median, 15 days; interquartile range [IQR], 12–22 days) compared with patients not taking warfarin (median, 13 days; IQR, 9–20 days; p < 0.001). Survival analysis to June 2015 showed a higher mortality for patients taking warfarin (12-month survival, 66% vs 76%; hazard ratio, 1.57; 95% CI, 1.21–2.04; p < 0.001).ConclusionsAfter controlling for multiple prognostic factors such as age, ASA score, AMTS, and WAI, warfarin therapy at the time of injury is associated with increased time to surgery, length of stay, and decreased survival. This study highlights the need to view warfarin therapy as a ‘red flag’ in patients presenting with a fractured neck of the femur. Preoperatively, prompt warfarin reversal together with adequate investigation and optimization of the patient should ensure timely, safe surgery. Early involvement of the anesthesia team should ensure an appropriate level of postoperative care for these patients.Level of EvidenceLevel III, therapeutic study

Bisphosphonates and atypical subtrochanteric fractures of the femur

Objectives Bisphosphonates are widely used as first-line treatment for primary and secondary prevention of fragility fractures. Whilst they have proved effective in this role, there is growing concern over their long-term use, with much evidence linking bisphosphonate-related suppression of bone remodelling to an increased risk of atypical subtrochanteric fractures of the femur (AFFs). The objective of this article is to review this evidence, while presenting the current available strategies for the management of AFFs. Methods We present an evaluation of current literature relating to the pathogenesis and treatment of AFFs in the context of bisphosphonate use. Results Six broad themes relating to the pathogenesis and management of bisphosphonate-related AFFs are presented. The key themes in fracture pathogenesis are: bone microdamage accumulation; altered bone mineralisation and altered collagen formation. The key themes in fracture management are: medical therapy and surgical therapy. In addition, primary prevention strategies for AFFs are discussed. Conclusions This article presents current knowledge about the relationship between bisphosphonates and the development of AFFs, and highlights key areas for future research. In particular, studies aimed at identifying at-risk subpopulations and organising surveillance for those on long-term therapy will be crucial in both increasing our understanding of the condition, and improving population outcomes. Cite this article: N. Kharwadkar, B. Mayne, J. E. Lawrence, V. Khanduja. Bisphosphonates and atypical subtrochanteric fractures of the femur. Bone Joint Res 2017;6:144–153. DOI: 10.1302/2046-3758.63.BJR-2016-0125.R1.

Data errors in the National Hip Fracture Database: a local validation study

AIMS We present an audit comparing our level I major trauma centres data for a cohort of patients with hip fractures in the National Hip Fracture Database (NHFD) with locally held data on these patients. PATIENTS AND METHODS A total of 2036 records for episodes between July 2009 and June 2014 were reviewed. RESULTS The demographics of nine patients were recorded incorrectly. The rate of incorrect data in operation codes was most significant with overall accuracy of 0.637 (95% CI 0.615 to 0.658). The sensitivity of NHFD coding ranged from 0.250 to 1.000 and the specificity 0.879 to 0.999. The recording of cementation had a sensitivity of 0.932 and specificity of 0.713. The recording of total hip arthroplasty had a sensitivity of 0.739 and specificity of 0.983. The overall accuracy of mortality data was 0.942 (95% CI 0.931 to 0.952), with sensitivity of 0.967 and specificity of 0.419. CONCLUSION This paper highlights the need for local audit of the integrity of data uploaded to the NHFD. Cite this article: Bone Joint J 2016;98-B:1406-9.

Delayed Presentation of Gluteal Compartment Syndrome: The Argument for Fasciotomy

A male patient in his fifties presented to his local hospital with numbness and weakness of the right leg which left him unable to mobilise. He reported injecting heroin the previous morning. Following an initial diagnosis of acute limb ischaemia the patient was transferred to a tertiary centre where Computed Tomography Angiography was reported as normal. Detailed neurological examination revealed weakness in hip flexion and extension (1/5 on the Medical Research Council scale) with complete paralysis of muscle groups distal to this. Sensation to pinprick and light touch was globally reduced. Blood tests revealed acute kidney injury with raised creatinine kinase and the patient was treated for rhabdomyolysis. Orthopaedic referral was made the following day and a diagnosis of gluteal compartment syndrome (GCS) was made. Emergency fasciotomy was performed 56 hours after the onset of symptoms. There was immediate neurological improvement following decompression and the patient was rehabilitated with complete nerve recovery and function at eight-week follow-up. This is the first documented case of full functional recovery following a delayed presentation of GCS with sciatic nerve palsy. We discuss the arguments for and against fasciotomy in cases of compartment syndrome with significant delay in presentation or diagnosis.

Virtual reality hip arthroscopy simulator demonstrates sufficient face validity

PurposeTo test the face validity of the hip diagnostics module of a virtual reality hip arthroscopy simulator.MethodsA total of 25 orthopaedic surgeons, 7 faculty members and 18 orthopaedic residents, performed diagnostic supine hip arthroscopies of a healthy virtual reality hip joint using a 70° arthroscope. Twelve specific targets were visualised within the central compartment; six via the anterior portal, three via the anterolateral portal and three via the posterolateral portal. This task was immediately followed by a questionnaire regarding the realism and training capability of the system. This consisted of seven questions addressing the verisimilitude of the simulator and five questions addressing the training environment of the simulator. Each question consisted of a statement stem and 10-point Likert scale. Following similar work in surgical simulators, a rating of 7 or above was considered an acceptable level of realism.ResultsThe diagnostic hip arthroscopy module was found to have an acceptable level of realism in all domains apart from the tactile feedback received from the soft tissue. 23 out of 25 participants (92%) felt the simulator provided a non-threatening learning environment and 22 participants (88%) stated they enjoyed using the simulator. It was most frequently agreed that the level of trainees who would benefit most from the simulator were registrars and fellows (22 participants; 88%). Additionally, 21 of the participants (84%) agreed that this would be a beneficial training modality for foundation and core trainees, and 20 participants (80%) agreed that his would be beneficial for consultants.ConclusionsThis VR hip arthroscopy simulator was demonstrated to have a sufficient level of realism, thus establishing its face validity. These results suggest this simulator has sufficient realism for use in the acquisition of basic arthroscopic skills and supports its use in orthopaedics surgical training.Level of evidenceI.

Current concepts and future perspectives in computer-assisted navigated total knee replacement

BackgroundTotal knee replacements (TKR) aim to restore stability of the tibiofemoral and patella-femoral joints and provide relief of pain and improved quality of life for the patient. In recent years, computer-assisted navigation systems have been developed with the aim of reducing human error in joint alignment and improving patient outcomes.MethodsWe examined the current body of evidence surrounding the use of navigation systems and discussed their current and future role in TKR.ResultsThe current body of evidence shows that the use of computer navigation systems for TKR significantly reduces outliers in the mechanical axis and coronal prosthetic position. Also, navigation systems offer an objective assessment of soft tissue balancing that had previously not been available. Although these benefits represent a technical superiority to conventional TKR techniques, there is limited evidence to show long-term clinical benefit with the use of navigation systems, with only a small number of studies showing improvement in outcome scores at short-term follow-up. Because of the increased costs and operative time associated with their use as well as the emergence of more affordable and patient-specific technologies, it is unlikely for navigation systems to become more widely used in the near future.ConclusionsWhilst this technology helps surgeons to achieve improved component positioning, it is important to consider the clinical and functional implications, as well as the added costs and potential learning curve associated with adopting new technology.

Close encounters of the blurred kind

Abstract We present a visually arresting scout image obtained during a CT head scan of an elderly patient for assessment of new onset confusion. The patient moved during the scout image acquisition resulting in distortion of the cranial vault that never the less remained largely in focus.

From Cape Town to Cambridge: Orthopaedic trauma in contrasting environments

AIM To compare the trauma experience gained by a trainee at a United Kingdom major trauma centre and a secondary level hospital in South Africa. METHODS A profile of inpatient trauma cases during a five-week period in Addenbrookes Hospital, Cambridge and Somerset Hospital, Cape Town was created. This was achieved by recording various parameters for each patient admitted including age, gender, injury, mechanism of injury and postal/area code. This, together with details of the departments themselves, allows a comparison of the amount and variety of orthopaedic trauma cases experienced by an individual trainee in each setting. RESULTS The trauma profiles differed significantly. Patients in Cape Town were younger and more likely to be male. In the young, injury in Cape Town was more likely to occur due to assault or being struck by a vehicle, whilst patients in Cambridge were more likely to be injured whilst in a vehicle or in high energy falls. In older patients, trauma at both centres was almost exclusively due to mechanical falls. In a given age group, injuries at the two centres were similar, however the majority of patients admitted to Addenbrookes were elderly, resulting in less variation in the overall injury profile. CONCLUSION The trauma profile of a major trauma centre in the United Kingdom is less varied than that of a South African secondary centre, with significantly fewer cases per surgeon. This suggests a more varied training experience in the developing world with a greater caseload.

Giant intradiploic epidermoid cyst with intracranial extension

A 47-year-old gentleman presented to our institution with a 24 h history of worsening headache, increasing confusion and drowsiness. He was afebrile and there were no signs of meningism. No focal neurological deficits were present. A palpable scalp lump was found on examination in the left posterior frontal/parietal area. The lump had been present since childhood according to the patient. There was no clear history of head trauma but he had participated in a mosh pit a few days prior to his presentation. A contrast CT scan of the head revealed a large extra-axial lesion that was centred in the posterior part of the left parietal bone and had a significant intractranial component (Fig. 1). An MRI brain showed some areas of T1 hyperintensity within the lesion, suggestive of blood degradation products (Fig. 2).