A qualitative study to understand patients' experiences of their post-operative outcomes following forefoot surgery.

Background: Hallux valgus and hallux rigidus are two common forefoot conditions causing deformity, pain, functional limitations, disability and deteriorating health status resulting in the requirement for surgery. Even when surgery is performed by an experienced surgeon, there remains a potential for patients to experience dissatisfaction and unfavourable outcomes. Adverse results are moderated by psychosocial variables; however, there is a paucity of qualitative research providing insight into how patients perceive their outcomes and the factors affecting their recovery. Objective: The study aimed to qualitatively explore patients' experiences of their surgical outcomes following forefoot surgery and factors associated with their recovery. Semi-structured interviews with 15 patients who received surgery for hallux valgus and/or hallux rigidus were conducted. Results: Thematic analysis generated five themes: physical limitations, the psychosocial impact of surgical recovery, regaining normality, patients' expectations for physical recovery and an altered body-image. Physical and psychosocial factors were inter-related. Patients experiencing problematic outcomes were functionally limited, had low mood and were unable to return to a normal life post-surgery. The women reported weight related issues and were limited in their footwear and clothing choices, negatively impacting on their self-esteem. Conclusion: A forefoot condition is multifaceted, with patients experiencing a range of physical and psychological factors that may influence their outcomes and recovery from surgery. Patients need to be supported holistically with the use of a biopsychosocial model. A multidisciplinary approach to care and treatment within the forefoot surgical pathway with the inclusion of allied health professionals will enable to better support patients to enhance their outcomes.

Ceramic Bearings Are Associated With a Significantly Reduced Revision Rate in Primary Hip Arthroplasty: An Analysis From the National Joint Registry for England, Wales, Northern Ireland, and the Isle of Man.

BACKGROUND: Prosthetic joint infection (PJI) is a devastating complication. Studies have suggested reduction in PJI with the use of ceramic bearings. METHODS: Adult patients who underwent total hip arthroplasty (THA) using an uncemented acetabular component with ceramic-on-ceramic (CoC), ceramic-on-polyethylene (CoP), or metal-on-polyethylene (MoP) bearing surfaces between 2002 and 2016 were extracted from the National Joint Registry for England, Wales, Northern Ireland, and the Isle of Man. A competing risk regression model to investigate predictors of each revision outcome was used. Time-to-event was determined by duration of implantation since primary surgery with competing risks being death or revision. The results were adjusted for age, gender, American Association of Anaesthesiologists grade, body mass index, surgical indication, intraoperative complications, and implant data. RESULTS: In total, 456,457 THAs (228,786 MoP, 128,403 CoC, and 99,268 CoP) were identified. Multivariable modeling showed that the risk of revision for PJI was significantly lower with CoC (risk ratio 0.748, P < .001) and CoP (risk ratio 0.775, P < .001) compared to MoP. Significant reduction in risk of aseptic and all-cause revision was also seen. The significant protective effect of ceramic bearing was predominantly seen 2 years after implantation. Aseptic revision beyond 2 years reduced by 18.1% and 24.8% for CoC and CoP (P < .001), respectively. All-cause revision rate beyond 2 years reduced by 21.6% for CoC and 27.1% for CoP (P < .001) CONCLUSION: This study demonstrates an association between the use of ceramic as part of the bearing, with lower rates of revision for all causes, revision for infection, and revision for aseptic causes, supporting ceramic bearings in THA.

Occurrence, management and outcomes of hip fractures in patients with Parkinson's disease.

INTRODUCTION: Hip fractures can be debilitating, especially in patients with pre-existing Parkinson's disease; they have reportedly worse outcomes than non-Parkinson's disease patients. SOURCES OF DATA: A computerized literature search on PubMed, Medline, Embase, and CINAHL, supplemented by a manual search of related publications. AREAS OF AGREEMENT: Parkinson's disease patients were found to have significantly lower bone mineral density; higher incidence of falls and hip fractures; delays to receiving their Parkinson's disease medication and surgery; higher risk of pneumonia, urinary infection, pressure sores, post-operative mortality; surgical complications and sequelae, including failed fixation, dislocation, longer hospital stay, re-operation; and increased risk of contralateral hip fracture. AREAS OF CONTROVERSY: Regain of mobility and return to previous residential status have been variably reported. GROWING POINTS: All Parkinson's disease patients should be screened and considered for primary prevention treatment. On admission with hip fractures, attention should be paid to avoid delays to medication, ensuring safe anaesthetic and timely surgery, and post-operative chest physiotherapy and mobilization. RESEARCH: Research is needed in minimizing the bone-resorptive effects of anti-Parkinson's disease medication.

Mid-term survival following primary hinged total knee replacement is good irrespective of the indication for surgery.

PURPOSE: The use of 'hinged' knee prostheses for primary knee arthroplasty procedures is increasing. This analysis reports the rates of implant survival, modes of failure, revision details and functional outcomes with particular reference to the primary indication for surgery for a cohort of patients treated with primary hinged knee replacement. METHODS: Systematic review with supplementary analysis using data from the National Joint Registry and Department of Health. Analysis included 964 patients undergoing primary hinged knee replacement between April 2003 and December 2010. Survival at a maximum of 7 years was calculated for the group as a whole and dependent upon the indication for surgery (osteoarthritis vs. rheumatoid/inflammatory arthritis vs. post-traumatic arthritis). Functional outcomes (pre- and post-operative Oxford Knee and Euroqol-5D scores and post-operative satisfaction) were available for 46 patients. RESULTS: In total, 20 cases required revision. The 5-year survival rate (96.8% [95% CI 95.1-98.4%]) was not dependent upon the primary surgical indication (p = n.s.). The commonest reasons for revision were infection (8 cases), peri-prosthetic fracture (4 cases) and aseptic loosening (3 cases). Patients reported substantial improvements in their Oxford Knee Score (mean improvement = 17.6, [95% CI 14.4-20.8]) and EQ5D index (mean improvement = 0.357, [95% CI 0.248-0.467]). Levels of post-operative satisfaction were high. CONCLUSIONS: Hinged knee replacement can be considered as a viable alternative to more traditional unconstrained designs in the complex primary setting. These findings are clinically relevant as they support the increasing use of hinged knee replacements for the arthritic knee in which there is concomitant severe bone loss, deformity or instability. Surgeons using these implants can have confidence that their mid-term performance is comparable to more conventional knee designs. LEVEL OF EVIDENCE: Prospective cohort study, Level II.

Center and surgeon volume influence the revision rate following unicondylar knee replacement: an analysis of 23,400 medial cemented unicondylar knee replacements.

BACKGROUND: Revision rates following unicondylar knee replacement vary among reporting institutions. Revision rates from institutions involved in the design of these implants and independent single-center series are comparable with those following total knee replacement, suggesting that higher operative volumes and surgical enthusiasm improve revision outcomes. METHODS: This registry-based cohort study involved the analysis of 23,400 medial cemented Oxford unicondylar knee replacements for the treatment of osteoarthritis. Total center and surgeon operative volumes were calculated over an eight-year time span since the inception of the registry (April 2003 to December 2010). The revision rate was calculated according to center volume and surgeon volume, each of which was grouped into five categories. The groups were compared with use of life tables, Kaplan-Meier plots, and Cox regression models that adjusted for variations in age, sex, and American Society of Anesthesiologists (ASA) grade among the groups. RESULTS: A total of 919 surgeons and a total of 366 centers performed at least one replacement, with the majority performing a small number of procedures. The revision rate for the centers with the lowest volume (fifty or fewer procedures over the eight-year study period) was 1.62 (95% confidence interval [CI], 1.42 to 1.82) revisions per 100 component years; this was significantly higher than the rate for the centers with the highest volume (more than 400 procedures), which was 1.16 (95% CI, 0.97 to 1.36) revisions per 100 component years. The five-year implant survival rate of 92.3% (95% CI, 91.2% to 93.3%) for the lowest-volume centers was significantly lower than the rate of 94.1% (95% CI, 93.0% to 95.2%) for the highest-volume centers. Similarly, the revision rate for the surgeons with the lowest volume (twenty-five or fewer procedures), 2.16 (95% CI, 1.91 to 2.41) revisions per 100 component years, was significantly higher than that for the surgeons with the highest volume (more than 200 procedures), 0.80 (95% CI, 0.62 to 0.98) revisions per 100 component years. The five-year survival rate of 90.1% (95% CI, 88.8% to 91.3%) for the lowest-volume surgeons was also significantly lower than the rate of 96.0% (95% CI, 95.0% to 97.0%) for the highest-volume surgeons. When center and surgeon volume were considered simultaneously, the hazard of revision was greater for lower-volume surgeons at lower-volume centers compared with higher-volume surgeons at higher-volume centers (hazard ratio = 1.87 [95% CI, 1.58 to 2.22], p < 0.001). CONCLUSIONS: High-volume centers and surgeons specializing in such procedures had superior results following unicondylar knee replacement compared with their low-volume counterparts. These results suggest that centers and surgeons should undertake a minimum of thirteen such procedures per year to achieve results comparable with the high-volume operators.

Invasive biopsy is effective and useful after lung transplant.

BACKGROUND: Transbronchial biopsy (TBB) is widely used after lung transplant but may not be diagnostic. Our group has used invasive approaches, open lung biopsy (OLB) or video-assisted thoracoscopy (VAT), to establish a definitive diagnosis in unexplained clinical deterioration. We sought to demonstrate the risks and benefits of this approach. METHODS: A retrospective review was made of the case notes of the patients undergoing OLB or VAT during a 12-year period from August 1996. RESULTS: During a 12-year period in 442 recipients, there were 51 invasive biopsies in 45 patients (6 had 2 procedures), of which 41 (80%) were OLB and 10 (20%) were VAT. Time of biopsy ranged from 7 days to 11 years after transplant. Thirty-seven (73%) took place in the first year, including 12 (24%) within the first 30 days. Nine patients died within 30 days of biopsy; 7 of them were already ventilated. Overall, biopsy provided a new unsuspected diagnosis in 37% of patients and confirmed the diagnostic suspicion in 47%. In only 16% of patients did it fail to provide a result that was clinically useful. The results of 29 (57%) biopsies led to a change in treatment. Sixty-three percent of new diagnoses and 71% where clinical suspicion was confirmed resulted in a treatment change. In all but 2 cases, a change was made to medication. CONCLUSIONS: In this large series of invasive biopsies, there was a high rate of useful results, with a frequent change in treatment. Invasive biopsies are a safe intervention in ambulatory patients.

Genetically engineered E. coli as a protein delivery vehicle for killing cancer cells.

Extract: The beneficial effects of bacteria on rejection of and resistance to tumors have been observed since the 18th century. Physicians have recorded hundreds of cases of spontaneous regression of many types of cancer following bacterial infections, such as staphylococcal or mixed infections, or bacterial vaccines. For example, significantly lower recurrence and number of metastases were recorded in sarcoma patients with concurrent streptococcal infection occurring either spontaneously or by inoculation. More recently, a decreased incidence of malignancy has been recorded in areas or subsets of populations where infectious diseases are endemic. For example, a Swiss study of hospitalized patients over a 20 year period recorded that the previous incidence of acute infections and acute inflammatory episodes was almost nil in groups of cancer patients, compared with a much higher incidence in the non-cancerous groups. Studies in the 1960s with Clostridium showed that this anaerobic bacterium could selectively target and grow inside experimental tumors in mice, leading to tumor regression. However, clinical trials with Clostridium had to be abandoned due to severe toxicities. In the last few years interest in using bacteria as cancer therapies has been reignited. Advances in genetic engineering have enabled modifications of bacteria to reduce toxicity, however, clinical trials with attenuated bacteria such as Salmonella have failed to provide therapeutic benefits that outweigh toxicities in cancer patients.