Wrightington Hospital

Proximal radio-ulnar stump impingement (PRUSI) describes a painful condition occurring following radial head loss. Pain occurs due to the proximal radial stump impinging against the ulna. This study aimed to evaluate the safety of a novel interposition arthroplasty method. A retrospective observational consecutive case series study was undertaken from case note review of patients with PRUSI, treated by Achilles allograft interposition arthroplasty. The technique utilised donor Achilles tendons to cushion the proximal radio-ulnar stump articulation. The primary outcome was a change in pain levels. Secondary outcomes included changes in: elbow and forearm range of movement, Mayo Elbow Performance Score (MEPS), patient satisfaction on an 11-point numerical rating scale (NRS) and adverse events. From baseline to six months post intervention, the mean NRS pain score was reduced from 9/10 to 2/10 with a mean difference in NRS pain scores of -7 (95% CI -4, -10; p = 0.004). Mean MEPS increased from 56/100 (s.d. 8) to 91 (s.d. 8), with a mean difference of 35/100 (95% CI 18, 52; p = 0.005). Achilles tendon allograft arthroplasty represents a safe procedure for treating PRUSI. This IDEAL phase 1 study shows promising results, indicating the need for further trials.

Major reoperation (hereafter referred to as ‘reoperation’) without revision of implants can leads to significant patient morbidity and mortality, and most commonly occurs when the femur fractures around an implant (postoperative periprosthetic femoral fractures; POPFF) and is treated with fixation and the implant is left in place. Reliance on revision metrics that do not capture these reoperation s has led to large-scale under reporting of failures in THR, and is likely to have affected implant performance estimates, which have guided national policy and implant selection. We aimed to estimate the incidence of reoperation following primary.We analysed a mandatory, prospective database, the National Joint Registry (NJR), linked to Hospital Episode Statistics (HES). All linkable primary THRs using recently available implants, with highest safety rating between 01/01/2010 to 31/12/2020 were included. Reoperation was defined as the first revision for any cause or fixation of POPFF and was identified using a combination of procedural and diagnosis codes.We identified 452,901 THRs representing 2,558,325 prosthesis years at risk. A total of 9,407 reoperations were identified that had been surgically treated by revision for any cause or fixation of POPFF. The incidence of reoperation was 3.68 (95% CI 3.60, 3.75) per 1000 prostheses years in comparison to 3.03 (95% CI 2.96 to 3.10%) per 1000 prostheses years when using conventional revision only outcomes. Cumulative incidence of major reoperation at ten years was 3.0% (95% CI 2.9 to 3.0%). In older men collared cementless stems performed better than cemented stems and in older women the trend was reversed.Rates in older men were lowest with cementless collared stems, and in older women reoperation rates were lowest with cemented polished taper stems made of stainless steel. These results prompt a review of the current implant guidance for hip replacements in older patients.

Unreconstructible distal humerus fractures have been managed with total elbow replacement (TER), but there is increasing use of hemi-replacement (DHH). Pain has been identified as the most important outcome by patients. This study aims to systematically review the literature on reported pain outcomes in adult distal humerus fractures treated with TER or DHH. Medline, Embase and Central were searched using OVID, from January 2000 to September 2023, for studies in adults undergoing DHH or TER for acute closed distal humerus fractures. The primary outcome was patient-rated pain measured on a numerical rating scale. A quantitative summary of reported outcomes was stratified by intervention type. Twenty-three studies met the inclusion criteria, including one published randomised controlled trial. Meta-analysis found a pooled average NRS pain for TER of 1.7/10 (95% CI: 0.44-2.99) and 1.5/10 for DHH (95% CI: 0.001-3.56). On a 4-point Likert scale the pooled probability of no pain, mild pain, moderate pain, severe pain for TER was 0.75, 0.21, 0.02, 0.00 and for DHH was 0.76, 0.11, 0.12, and 0.00. The available evidence does not enable comparison of pain outcomes between the interventions, which should be assessed in an appropriately powered randomised trial.

The aim of this audit was to assess and improve the completeness and accuracy of the National Joint Registry (NJR) dataset for arthroplasty of the elbow. It was performed in two phases. In Phase 1, the completeness was assessed by comparing the NJR elbow dataset with the NHS England Hospital Episode Statistics (HES) data between April 2012 and April 2020. In order to assess the accuracy of the data, the components of each arthroplasty recorded in the NJR were compared to the type of arthroplasty which was recorded. In Phase 2, a national collaborative audit was undertaken to evaluate the reasons for unmatched data, add missing arthroplasties, and evaluate the reasons for the recording of inaccurate arthroplasties and correct them. Phase 1 identified 5,539 arthroplasties in HES which did not match an arthroplasty on the NJR, and 448 inaccurate arthroplasties from 254 hospitals. Most mismatched procedures (3,960 procedures; 71%) were radial head arthroplasties (RHAs). In Phase 2, 142 NHS hospitals with 3,640 (66%) mismatched and 314 (69%) inaccurate arthroplasties volunteered to assess their records. A large proportion of the unmatched data (3,000 arthroplasties; 82%) were confirmed as being missing from the NJR. The overall rate of completeness of the NJR elbow dataset improved from 63% to 83% following phase 2, and the completeness of total elbow arthroplasty data improved to 93%. Missing RHAs had the biggest impact on the overall completeness, but through the audit the number of RHAs in the NJR nearly doubled and completeness increased from 35% to 70%. The accuracy of data was 94% and improved to 98% after correcting 212 of the 448 inaccurately recorded arthroplasties. The rate of completeness of the NJR total elbow arthroplasty dataset is currently 93% and the accuracy is 98%. This audit identified challenges of data capture with regard to RHAs. Collaboration with a trauma and orthopaedic trainees through the British Orthopaedic Trainee Association improved the completeness and accuracy of the NJR elbow dataset, which will improve the validity of the reports and of the associated research.

Periprosthetic joint infection (PJI) is considered a rare but devastating complication after total joint arthroplasty (TJA). The problem lies in the fact that there is a paucity of "gold standard" diagnostic tests that make the diagnosis of PJI extremely challenging. Recently, there have been increasing evidence-based guidelines that have been introduced to standardise the approach to a patient with a suspected PJI. Diagnosing a case of PJI traditionally involves initial screening for elevated serum inflammation markers C-reactive protein (CRP) (mg/dL) and erythrocyte sedimentation rate (ESR), and aspiration remains the sole confirmatory investigation. However, several factors would affect the values of the aforementioned markers, such as gender, age, and the presence of inflammatory circumstances. Serum D-dimer that detects fibrinolytic activities during infection has high sensitivity, but the specificity was not persuasive as it would elevate during other conditions, such as venous thromboembolism. Therefore, there is also a need for a simultaneous and secondary marker. There are also several synovial biomarkers, including ESR, CRP, alpha-defensin, and synovial fluid leukocyte count and differential for the detection of PJI. In this narrative review, we want to sum up the serum and inflammatory markers that have been introduced so far for detecting PJI.

Please confirm that an ethics committee approval has been applied for or granted: Not relevant (see information at the bottom of this page)Background and AimsThe Royal College Of Anaesthesia (RCOA) 2021 curriculum mandates Anaesthetists in Training (AIT) to master all PLAN A blocks by CCT. Regular practice and ultrasound workshops are pivotal for training in regional anaesthesia (RA). To enhance RA training accessibility, we propose initiating a mobile RA club focusing on PLAN A BLOCKS and sharing credible online RA resources. Our objective is to gauge awareness of PLAN A BLOCKS, preferred RA learning sources, and receptiveness to establishing local Sono clubs in Northwest hospitals.MethodsA survey comprising 10 questions, including one open-ended query, was distributed to Northwest Anaesthetists, yielding 46 responses within 5 days.ResultsFindings reveal over 70% familiarity with PLAN A BLOCKS, yet most possess limited experience with upper limb and truncal blocks. Reputable online sources are favoured for individual learning, although nearly 70% do not engage with any online RA platform. Notably, 32% lacked RA training in the past year, while almost all expressed interest in localized RA teaching during hospital rotations.ConclusionsWhile progress in RA training and practice is evident in the region, opportunities for improvement persist. We have initiated the dissemination of coded reputable online resources, such as the Regional Anaesthesiology and Acute Pain Medicine YouTube channel, and plan to establish a mobile RA Club. This initiative will leverage advanced regional trainees’ rotations to new hospitals with the guidance of Local/visiting consultants. A mandatory 3-month regional rotation may be necessary in the future to further enhance RA proficiency. P125 Figure 1Awareness of plan A blocks P125 Figure 2Percentage of anaesthetists would appreciate local RA teaching P125 Figure 3RA online resources

BackgroundAcute unreconstructible 3- or 4-part proximal humerus fractures can be treated with hemiarthroplasty or reverse polarity shoulder arthroplasty. Randomized trials using implants from multiple different companies or uncemented implants have found superior results with reverse polarity arthroplasty. AimsThis study aims to determine whether cemented reverse polarity arthroplasty produces a superior outcome compared to cemented hemiarthroplasty using one implant system in patients aged 65 years and over at 12 months follow-up as measured with the Constant score. MethodsA prospective patient and assessor blinded multicenter randomized controlled trial was conducted of shoulder hemiarthroplasty or reverse polarity arthroplasty in patients aged 65 years and older with acute 3- and 4-part proximal humerus fracture not amenable to osteosynthesis. The primary outcome was the Constant score at 12 months with total follow-up to 24 months. Block randomization by site was undertaken using random number generation and sealed envelopes. Power analysis indicated that 17 patients were required in each arm to achieve 80% power with an alpha-value of 5%. Secondary outcome measures were the difference in the mean Constant Score, Quick Disabilities of the Arm Shoulder and Hand Questionnaire (QuickDASH), Oxford Shoulder Score (OSS), American Shoulder and Elbow Surgeons (ASES) Score and EQ5D-5L up to two years; differences in complication rate at one and two years; differences in revision and implant failure at one and two years. Results18 patients were randomized to hemiarthroplasty and 18 to reverse polarity arthroplasty across 4 sites. The primary outcome as measured by the Constant score at 12 months was better in the reverse polarity shoulder arthroplasty (RSA) group (Mean 51.1, s.d. 14.9) compared to the hemiarthroplasty (HA) group (mean 35.0, s.d. 13.5) (p=0.004). No significant difference was reported at 24 months but this may be due to high rates of attrition (22%). The mean EQ-5D-5L patient rated health status score was significantly higher in the RSA group compared to the HA group at 12 months. One hemiarthroplasty was revised due to implant uncoupling and one reverse polarity shoulder replacement was revised due to instability. No other complications were recorded. DiscussionTreatment of unreconstructible 3- or 4-part proximal humerus fractures with reverse polarity shoulder arthroplasty results in a superior outcome compared to shoulder hemiarthroplasty at 12 months measured with the Constant score with no increased risk of failure up to 24 months in patients age 65 years and over. High attrition rates are observed in this older population due to cognitive decline and death from other causes.

The successful management of wound healing after total knee arthroplasty (TKA) depends on several aspects of ancillary intraoperative techniques and surgical variables. Many of these have been evaluated in a few recent reports. The prior reviews studied many aspects of wound healing and, for example, found lower risks of wound complications with barbed sutures compared with interrupted closure with non-barbed sutures, no differences in wound complications between adhesives, subcuticular sutures, staples, glue, or mesh adhesives for the closure of the skin layer, and that mesh adhesives may be associated with faster closing times compared to subcuticular sutures or staples in TKA. However, some topics that can be influenced by the surgeon were not covered in these previous reviews. Namely, the use of deep vein thrombosis (DVT) prophylaxis, tourniquet application, management of intraoperative drains, surgical approach selection, and patellar handling techniques can all potentially influence wound healing. Therefore, in this comprehensive systematic review of the literature, we focused on these five factors that may influence wound healing. Specifically, we evaluated: (1) the impact of different DVT prophylaxis methods on wound healing and infection rates; (2) the role of tourniquet application on wound closure and potential infection risks; (3) the effects of intraoperative drain usage on wound healing; (4) the influence of different surgical approaches on wound closure and postoperative infection rates; and (5) the effects of varying patellar handling strategies on wound healing and infection rates. A systematic search of electronic databases, including PubMed, Cochrane Library, Medline, and Embase, was conducted to identify studies assessing auxiliary surgical techniques and their impact on wound healing in total knee arthroplasty (TKA). Relevant terms like "knee," "arthroplasty," and "wound healing" refined the search, which included English language publications until May 1, 2023. Independent screening by two authors and a third mediator facilitated the selection process, with 24 studies meeting the criteria. Assessment of these studies involved evaluating their evidence level and methodological quality using the Modified Coleman Methodology Score (MCMS). A comparison was made on wound healing outcomes in TKA, which included evaluating methodological quality parameters like sample sizes, follow-up durations, and clinical effect measurements. Data synthesis for the studies provided a comprehensive summary, categorizing them by evidence level. There were seven reports on DVT prophylaxis that showed no statistically significant differences in wound complications among various treatment methods and medications in patients undergoing total knee arthroplasty (TKA), with wound complication rates ranging from 0.25 to 1%, except that aspirin appeared to have lower wound complications rates in three recent studies than other methods. There were five reports on tourniquet application that showed a generally increased rate of wound complications, but no increase in deep infections. The five reports on intraoperative drain use showed that while there is an increase in total blood loss in the group with drains, ranging from 568ml to 1,856ml, compared to 119ml to 535ml in the no-drain group, there are no significant differences in wound complications, infection rates, or other postoperative outcomes such as swelling, deep vein thrombosis, and range of motion between the drain and no-drain groups. There were three studies on surgical approaches revealing no differences in wound complication rates between the mini-subvastus and medial parapatellar incisions. Also, the surgical variables of patella eversion and anterior tibial translation were only studied in one report. The current literature highlights the importance of using aspirin when possible for DVT prophylaxis and the possibility that tourniquets may lead to increased superficial wound complications. Drains or surgical approach do not appear to lead to wound problems. Surgical variables, such as patella eversion and anterior tibial translation, need more study.