Musgrave Park Hospital

Persistent anemia in older adults is commonly attributed to nutritional deficiency, chronic disease, or age-related change, particularly when routine laboratory investigations are unrevealing. However, plasma cell and lymphoplasmacytic disorders may present subtly, with anemia as the only consistent abnormality. We report two cases in which extended laboratory evaluation led to early identification of clinically significant B-cell malignancies.The first case involved a man in his early 70s with stable, asymptomatic normocytic anemia despite normal iron studies, vitamin B12 and folate levels, renal function, thyroid studies, and liver enzymes. Serum protein electrophoresis revealed a monoclonal immunoglobulin G kappa paraprotein with an abnormal serum free light-chain ratio. Bone marrow biopsy confirmed clonal plasma cell infiltration consistent with smoldering multiple myeloma, and imaging demonstrated no myeloma-defining bone disease. The patient remains under active surveillance.The second case involved a man in his late 70s with a several-year history of progressive macrocytic anemia and repeatedly normal first-line investigations. Extended testing revealed a marked immunoglobulin M lambda monoclonal gammopathy, and bone marrow biopsy confirmed Waldenström macroglobulinemia. He required treatment due to severe anemia and responded to bendamustine-rituximab therapy.These cases highlight the diagnostic value of serum protein electrophoresis, quantitative immunoglobulins, and serum free light-chain testing in patients with persistent unexplained anemia. Early use of extended investigations can facilitate timely diagnosis before end-organ damage occurs and details the critical role of primary care clinicians in recognizing patterns that warrant escalation beyond routine anemia algorithms.

Patients with ankylosing spondylitis (AS) are vulnerable to cervical spinal fractures despite minute trauma. As there is a lack of consensus on which surgical approach is the most efficacious in treating cervical spinal fractures in AS patients, we sought to compare the posterior-only and combined (anterior-posterior) approach regarding intraoperative and postoperative complications. This systematic review was registered with the International Prospective Register of Systematic Reviews (PROSPERO) database (ID: CRD42024284877). Studies published up to May 20, 2025, were searched in PubMed, MEDLINE, and CENTRAL (Cochrane Central Register of Controlled Trials) with predetermined terms. Studies reporting outcomes, including intraoperative and postoperative complications and mortality rate, were evaluated. Included studies underwent a risk of bias assessment. Seventeen studies (one prospective, 16 retrospective) involving 858 patients (with AS and cervical spine fractures) with an average age of 59.9 years were included. The most common mechanism of injury was minor trauma (173, 66%), and C6-7 was the most common level injured (185, 50.6%). Although the posterior-only approach yielded fewer intraoperative complications (4 (4.8%) vs. 2 (15%); p>0.05), postoperative complications (17 (7.5%) vs. 16 (22.6%); p>0.05), and instrument-related complications (1 (2.8%) vs. 3 (12.5%); p>0.05) compared to the combined approach, the difference was not statistically significant. However, the combined approach recorded a significantly lower mortality rate (3 (9.2%) vs. 13 (24.5%); p>0.05) when compared with the posterior-only approach. The results of this systematic review suggest that both the combined and posterior-only approaches have advantages and disadvantages and approach selection should be done on a case-by-case basis. Future randomized controlled trials directly evaluating the efficacy of surgical approaches in such patients are needed to form a consensus.

Abstract Aim Idiopathic Toe Walking (ITW), a common gait abnormality in children, leads to functional limitations and psychosocial challenges. However, the lack of robust evidence to guide treatment results in varied clinical practice. This study aimed to evaluate the clinical and kinematic outcomes of children with ITW one year postoperatively and assess whether these align with patient and parent satisfaction. Method A retrospective review (2012–2023) assessed children diagnosed with ITW who underwent bilateral Tendon Achilles Lengthening (TAL). Clinical assessment and 3-dimensional gait analysis were used to assess kinematic parameters, generating a movement analysis profile (MAP) and gait profile score (GPS). Follow-up evaluations occurred one year post-operatively, supplemented by satisfaction surveys for a sub-cohort of patients. Results 39 patients (22 boys/17 girls) and 35 patients (20 boys/15 girls) had complete pre and postoperative data for clinical assessment and 3-dimensional gait analysis respectively. Age at the time of operation averaged 11.3 years. Postoperative follow-up averaged 1.3 years. Autism spectrum disorder was diagnosed in 23% of patients. Daytime pain reduced significantly from 72% preoperatively to 15% postoperatively, while nighttime pain, reported in 10%, resolved entirely. Improvements were observed in ankle dorsiflexion and several MAP variables, suggesting better alignment with normative gait patterns. Additionally, GPS trends decreased postoperatively across the cohort. Patient and parent satisfaction outcomes were reported as excellent in 67% of responses. Conclusions The data suggests that TAL demonstrates efficacy in improving clinical and kinematic outcomes in ITW patients, reducing pain and achieving high levels of satisfaction among patients and parents.

Cancer care guidelines have been developed in many subspecialities, usually in advanced health systems. However, there are notable global disparities in healthcare access, which can impact sarcoma care. Unfortunately, there is a lack of global data on this subject. Our aim was to describe access to sarcoma care based on a comprehensive global survey among orthopaedic oncologists, and assess for global as well as regional differences. A 25-question survey was emailed to the attendees of the 2024 Birmingham Orthopaedic Oncology Meeting and included questions about the respondents' training and practice, access to sarcoma centres, and specific items for sarcoma diagnosis and treatment. For data analysis and comparison, countries were grouped geographically and per the World Bank's income classification. A total of 192 specialists from 47 countries completed the survey (67%). Overall, 40% declared that most patients in their country were treated in a specialized sarcoma centre. Declared access to specific diagnostic technology ranged from 69% (translocation studies) to 86% (various immunohistochemistry). Only 31% stated having access to proton therapy and 82% to all possible reconstruction methods. Compromise of ideal surgical management because of prior treatments and financial constraints was declared to have happened regularly in 40% and 17% of practices, respectively. Regions with better-developed healthcare systems had improved access to all aspects surveyed. Similar results were observed when comparing high-income countries against low- to middle-income countries. Our study highlights substantial global and regional disparities in access to sarcoma services, which could potentially impact clinical outcomes. Further studies are needed to clarify this reality.

The Birmingham Orthopaedic Oncology Meeting (BOOM), held in January 2024, convened 309 delegates from 53 countries to discuss and refine 21 consensus statements on the optimal management of chondrosarcoma. With representation from Europe (43%; n = 133), North America (17%; n = 53), South America (16%; n = 49), Asia (13%; n = 40), Australasia (5%; n = 16), the Middle East (4%; n = 12), and Africa (2%; n = 6), the combined experience of treating bone sarcomas among attendees totalled approximately 30,000 cases annually, equivalent to 66 years of experience in the UK alone. The meeting's process began with the formation of a local organizing committee, regional leads, and a scientific committee comprising representatives from 150 specialist units across 47 countries. Supported by major orthopaedic oncology organizations, the meeting used a modified Delphi process to develop consensus statements through online questionnaires, thematic groupings, narrative reviews, and anonymous pre-meeting polling. Strong (> 80%) consensus was achieved on 19 out of 21 statements, reflecting agreement among delegates. Key areas of consensus included the role of radiology in diagnosis and surveillance, the management of locally recurrent disease, and the treatment of dedifferentiated chondrosarcoma. Notably, there was agreement that routine chemotherapy has no role in chondrosarcoma treatment, and radiological surveillance is safe for intraosseous chondrosarcomas. Despite the overall consensus, areas of controversy remain, particularly regarding the treatment of atypical cartilage tumours and surgical margins. These unresolved issues underscore the need for further research and collaboration within the orthopaedic oncology community. BOOM represents the largest global consensus meeting in orthopaedic oncology, providing valuable guidance for clinicians managing chondrosarcoma worldwide. The consensus statements offer a reference for clinical practice, highlight key research priorities, and aim to improve patient outcomes on a global scale.

Developmental dysplasia of the hip (DDH) is common and is a source of potentially avoidable morbidity through childhood and adult life. Despite progress over the past century, there is a wide variation in policy, practice and outcomes between countries. This review considers information from a geographically wide range of locations to evaluate the impact of these variations and understand how these variations arise. The aim is to help clinicians and policymakers adopt the best practices for their population. There is a lack of randomized controlled trials to guide decisions on screening. Given the large numbers to treat and preexisting practices, it is unlikely that such trials of sufficient statistical power will be performed. However, many whole population studies are becoming available from different countries that allow an assessment and comparison of the impact of their strategies. Standardizing metrics in studies and defining late diagnosis would improve comparisons across studies. The general trend appears to favour universal screening to reduce the risk of late diagnosis, the need for surgery and the subsequent poorer outcomes. Notably, resource-constrained countries like Mongolia have successfully implemented universal screening, showing that effective strategies can be adopted regardless of resources.

The aim of this study was to determine both the incidence of, and the reoperation rate for, postoperative periprosthetic femoral fracture (POPFF) after total hip arthroplasty (THA) with either a collared cementless (CC) femoral component or a cemented polished taper-slip (PTS) femoral component. We performed a retrospective review of a consecutive series of 11,018 THAs over a ten-year period. All POPFFs were identified using regional radiograph archiving and electronic care systems. A total of 11,018 THAs were implanted: 4,952 CC femoral components and 6,066 cemented PTS femoral components. Between groups, age, sex, and BMI did not differ. Overall, 91 patients (0.8%) sustained a POPFF. For all patients with a POPFF, 16.5% (15/91) were managed conservatively, 67.0% (61/91) underwent open reduction and internal fixation (ORIF), and 16.5% (15/91) underwent revision. The CC group had a lower POPFF rate compared to the PTS group (0.7% (36/4,952) vs 0.9% (55/6,066); p = 0.345). Fewer POPFFs in the CC group required surgery (0.4% (22/4,952) vs 0.9% (54/6,066); p = 0.005). Fewer POPFFs required surgery in males with a CC than males with a PTS (0.3% (7/2,121) vs 1.3% (36/2,674); p < 0.001). Male patients with a PTS femoral component were five times more likely to have a reoperation for POPFF. Female patients had the same incidence of reoperation with either component type. Of those having a reoperation, 80.3% (61/76) had an ORIF, which could greatly mask the size of this problem in many registries.

Femoral de-rotational osteotomies are a safe and effective treatment for symptomatic excessive femoral anteversion or retroversion. The author's preferred technique for performing a de-rotational osteotomy is via a subtrochanteric transverse osteotomy with intramedullary nail fixation. We describe a method for guiding femoral de-rotation correction intra-operatively using a bubble inclinometer.

Whether increased BMI is associated with an increased risk of venous thromboembolism (VTE) is controversial. Despite this, BMI > 40 kg/m 2 remains a common cutoff for lower limb arthroplasty eligibility. Current United Kingdom national guidelines list obesity as a risk factor for VTE, but these are based on evidence that has largely failed to differentiate between potentially minor (distal deep vein thrombosis [DVT]), and more harmful (pulmonary embolism [PE] and proximal DVT) diagnoses. Determining the association between BMI and the risk of clinically important VTE is needed to improve the utility of national risk stratification tools. (1) In patients undergoing lower limb arthroplasty, is BMI 40 kg/m 2 or higher (morbid obesity) associated with an increased risk of PE or proximal DVT within 90 days of surgery, compared with patients with BMI less than 40 kg/m 2 ? (2) What proportion of investigations ordered for PE and proximal DVT were positive in patients with morbid obesity who underwent lower limb arthroplasty compared with those with BMI less than 40 kg/m 2 ? Data were collected retrospectively from the Northern Ireland Electronic Care Record, a national database recording patient demographics, diagnoses, encounters, and clinical correspondence. Between January 2016 and December 2020, 10,217 primary joint arthroplasties were performed. Of those, 21% (2184 joints) were excluded; 2183 were in patients with multiple arthroplasties and one had no recorded BMI. All 8033 remaining joints were eligible for inclusion, 52% of which (4184) were THAs, 44% (3494) were TKAs, and 4% (355) were unicompartmental knee arthroplasties; all patients had 90 days of follow-up. The Wells score was used to guide the investigations. Indications for CT pulmonary angiography for suspected PE included pleuritic chest pain, reduced oxygen saturations, dyspnea, or hemoptysis. Indications for ultrasound scans for suspected proximal DVT included leg swelling, pain, warmth, or erythema. Distal DVTs were recorded as negative scans because we do not treat them with modified anticoagulation. The division of categories was set at BMI 40 kg/m 2 , a common clinical cutoff used in surgical eligibility algorithms. Patients were grouped according to WHO BMI categories to assess for the following confounding variables: sex, age, American Society of Anesthesiologists grade, joint replaced, VTE prophylaxis, grade of operative surgeon, and implant cement status. We found no increase in the odds of PE or proximal DVT in any WHO BMI category. When comparing patients with BMI less than 40 kg/m 2 with those with a BMI of 40 kg/m 2 or higher, there was no difference in the odds of PE (0.8% [58 of 7506] versus 0.8% [four of 527]; OR 1.0 [95% CI 0.4 to 2.8]; p > 0.99) or proximal DVT (0.4% [33 of 7506] versus 0.2% [one of 527]; OR 2.3 [95% CI 0.3 to 17.0]; p = 0.72). Of those who received diagnostic imaging, 21% (59 of 276) of CT pulmonary angiograms and 4% (34 of 718) of ultrasounds were positive for patients with BMI less than 40 kg/m 2 compared with 14% (four of 29; OR 1.6 [95% CI 0.6 to 4.5]; p = 0.47) and 2% (one of 57; OR 2.7 [95% CI 0.4 to 18.6]; p = 0.51) for patients with BMI 40 kg/m 2 or higher. There was no difference in the percentage of CT pulmonary angiograms ordered (4% [276 of 7506] versus 5% [29 of 527]; OR 0.7 [95% CI 0.5 to 1.0]; p = 0.07) or ultrasounds ordered (10% [718 of 7506] versus 11% [57 of 527]; OR 0.9 [95% CI 0.7 to 1.2]; p = 0.49) for BMI less than 40 kg/m 2 and BMI 40 kg/m 2 or higher. Increased BMI should not preclude individuals from lower limb arthroplasty based on suspected risk of clinically important VTE. National VTE risk stratification tools should be based on evidence assessing clinically relevant VTE (specifically, proximal DVT, PE, or death of thromboembolism) only. Level III, therapeutic study.