Royal National Orthopaedic Hospital

Minimally invasive hallux valgus (HV) correction techniques, including minimally invasive chevron and Akin osteotomy (MICA) and metaphyseal extra-articular transverse and Akin osteotomy (META), offer favourable outcomes but are associated with unpredictable first metatarsal fractures. This study identifies predictive factors for first metatarsal fractures following minimally invasive HV surgery. This retrospective case-control study analyzed 370 patients (499 feet) who underwent minimally invasive HV correction between November 2017 and August 2024 at a tertiary orthopaedic centre. Cases from the learning curve, revision procedures, and patients lost to follow-up were excluded. Patients were classified according to the presence or absence of a first metatarsal fracture, and logistic regression analysis was conducted to determine the associated risk factors. First metatarsal fractures occurred in 5.4% (27 of 499 feet), with type II fractures being most common (40.7%). On multivariable logistic regression, both older age and simultaneous bilateral surgery were independently associated with fracture. The odds of fracture increased by 8.6% per year of age (OR 1.086 (95% CI 1.032 to 1.150); p = 0.003) and were higher in patients undergoing bilateral versus unilateral surgery (OR 4.02 (95% CI 1.75 to 9.80); p = 0.001). Bone mineral density of the femur and lumbar spine was not associated with fracture risk. Advanced age and bilateral surgery are key predictive factors for first metatarsal fractures following minimally invasive HV correction. Tailoring surgical and postoperative strategies, especially in elderly patients, may help mitigate fracture risk. Further research should explore metatarsal-specific bone density, surgical biomechanics, and younger patient cohorts.

A descriptive quantitative study. To determine how much and what type of exercises and training were provided as part of usual physiotherapy and occupational therapy to participants of the SCI-MT Trial (the Early and Intensive Motor Training for People with Spinal Cord Injuries Trial). This information is important because the SCI-MT Trial concluded that additional motor training is redundant if people with SCI receive equivalent usual care as what was provided to participants of the SCI-MT Trial. Fifteen spinal injury units across Europe and Australia. Data were collected on the time participants of both groups of the SCI-MT Trial (n = 220) attended physiotherapy and occupational therapy provided as part of usual care over the 10-week intervention period. The International Spinal Cord Injury Physical Therapy and Occupational Therapy Basic Data Set was used to capture time spent on activity and impairment directed categories of exercises and training. Participants attended a median (interquartile range) of 8.3 (6.2 to 11.4) hours of physiotherapy and occupational therapy per week. Approximately 70% of therapy time was spent actively exercising or training with a median of 3.8 h per week spent on activity-directedand 1.9 h per week spent on impairment-directedexercises and training. The results of this study detail the amount and type of physiotherapy and occupational therapy that needs to be provided as part of usual rehabilitation care to render additional motor training redundant.

In 2019, revision knee replacement (RevKR) services in England were reorganised into regional networks following the publication of clinical standards. These networks aim to improve outcomes through multidisciplinary decision-making and minimum surgical activity thresholds. This study examines changes in referral patterns, surgical volumes, and clinical outcomes before and after network implementation. RevKR procedures from 1 April 2012 to 31 December 2024 were identified using the Hospital Episode Statistics. Descriptive analysis of patient level national data assessed trends in referral patterns (based on mismatches between patient residence and surgical location), volumes, and outcomes. Low-volume surgeons (<10 cases/year) and units (<30 cases/year) were identified. The primary outcome was one-year re-revision. Secondary outcomes included 90-day mortality, readmissions, and length of stay. Across 67,363 procedures, out-of-area referrals remained stable, with slight increases in London. Since 2021, low-volume practise has declined nationally, particularly in the Northwest, London, and Northeast & Yorkshire. One-year re-revision rates improved from 11.4% in 2012 to 7.7% in 2023. However, 90-day mortality rose, possibly due to increasing patient complexity. Some regions showed reduced hospital stays between 2022 and 2024 compared to the pre-COVID era. The data suggest early signals of regions aligning with the implementation of revision networks, especially in the Northwest, Northeast & Yorkshire, and London regions. There are encouraging improvements in re-revision rates and hospital stays which may indicate potential benefits of the new model. As revision networks mature, strategies to increase surgical volume may be key to sustaining further improvements in patient outcomes.

Abstract Ideas and theories relevant to the discussions around mental health reform in Italy, the UK and Germany are described. Referring to papers identified in a 2024 search of the literature, descriptive outlines of the general course of mental health service development in the three countries are presented. There have been parallel trends of deinstitutionalisation and orientation towards community mental health care in all three countries but changes have followed different patterns: early and enduring orientation towards mental hospital closure and community mental health care in the UK, later and radical orientation towards mental hospital reform, mental hospital closure and community mental health care in Italy and slow but enduring mental hospital reform, general hospital psychiatry and a relatively late flourishing of community care and integrated care models in Germany. Patterns of service development were shaped by the foundations of National Health Service in Britain (1948) and Italy (1978), while developments in (West) Germany have been influenced by a regionalised purchaser- (health insurance-) provider system with a mixed economy of care. Theories and ideas ranging from Michel Foucault’s theoretical approach and Erving Goffman’s institutional analysis to phenomenological and existential philosophy have been important in contributing to (i) a strong person- and rights-focus in Italy, (ii) a combination of institutional critique and surviving institutional paradigm in Germany, and (iii) a tradition of institutional critique, empiricism and rights-based psychiatric reform for the UK.

➢ Neurological injury remains the most common reason for ligation following total hip arthroplasty.➢ The main risk factors for neurological injury following total hip arthroplasty are preexisting spinal pathology, revision surgery, complex hip anatomy, female sex, surgeon inexperience, and excessive limb lengthening.➢ Postoperative pelvic computed tomographic scans may be used to assess component positioning and identify any compressive hematomas. Magnetic resonance imaging with a metal artifact reduction protocol may be used to evaluate architectural changes in the affected nerve.➢ Electromyography and nerve conduction studies may help to assess the level and grade of the nerve injury. These tests are most useful when performed in patients who show no signs of neurological improvement 3 to 6 weeks after surgery.➢ The mainstay of nonoperative management is supportive care with physical therapy, an ankle-foot orthosis, and neuropathic pain treatment.➢ The prognosis for a femoral nerve injury is generally more favorable than that for a sciatic nerve injury following total hip arthroplasty.