Experience of an anatomic femoral stem in a UK orthopaedic centre beyond 20 years of follow-up.

INTRODUCTION: Increasing interest in the use of anatomical stems has developed as the prevalence of periprosthetic fractures (PPFs) continues to increase. The primary aim of this study was to determine the long-term survivorship and PPF rate of an anatomical femoral stem in a single UK centre. PATIENTS AND METHODS: Between 2000 and 2002, 94 consecutive THAs were performed using the 170 mm Lubinus SP II anatomical femoral stem in our institution. Patient demographics, operative details and clinical outcomes were collected prospectively in an arthroplasty database. Patient records and national radiographic archives were reviewed finally at a mean of 21.5 years (SD 0.7) following surgery to identify occurrence of subsequent revision surgery, dislocation or periprosthetic fracture. RESULTS: Mean patient age at surgery was 65.8 years (SD 12.5, 34-88 years). There were 48 women (51%). Osteoarthritis was the operative indication in 88 patients (94%). Analysis of all-cause THA failure demonstrated a survivorship of 98.5% (95% confidence interval [CI], 98.0-99.3%) at 10 years and 96.7% (94.5-98.9%) at 21 years. The 20-year stem survival for aseptic loosening was 100% with no cases of significant lysis found (lucent line > 2 mm) and no stems required revision. Patient demographics did not appear to influence risk of revision (p > 0.05). There were 2 revisions in total (2 for acetabular loosening with original stems retained). There were no PPFs identified at mean 21.5 year follow-up and 5 dislocations (5%). CONCLUSIONS: The Lubinus SP II 170 mm stem demonstrated excellent survivorship and negligible PPF rates over 20 years following primary THA.

[Myopia and Myopic Astigmatism in school-children]. / Miopía y Astigmatismo miópico en escolares.

INTRODUCTION: Worldwide, there is an epidemic increase in myopia. In children, the evidence points to a lack of ex posure to natural light. In Chile, the population situation of myopia in children is unknown. Objec tive: To estimate the tendency of myopia and myopic astigmatism in 1st- and 6th-grade students from the public education system in Chile. SUBJECTS AND METHOD: Ecological study based on diagnostic confirmations of the JUNAEB Medical Services Program, between 2012 and 2018. Annual country prevalence of myopia and astigmatism was estimated by region and sex. The screening evaluation included visual acuity using Snellen Eye Abbreviated chart, red reflex, Hirschberg test, Titmus test, Cover test, ocular motility, and anterior segment examination. Chi2 and logistic regression were used to assess differences and linear regression to estimate average annual change. RESULTS: Between 2012 and 2018, myopia and myopic astigmatism had a heterogeneous geographical presentation. Myopia and myopic astigmatism ≥ 3 dioptres increased by an annual average of 0.11% (R2 0.67) and 1.21% (R2 0.90), respectively, in 1st-grade children and by 0.2% (R2 0.65) and 8.7% (R2 0.79), respectively, in 6th-grade children. Myopia < 3 dioptres decreased by 0.13% annual average (R2 0.45) in 1st-grade children and myopic astigmatism < 3 dioptres by 0.5% (R2 0.53) in 6th-grade children. High myopic astigmatism affected men more than women and myopia < 3 dioptres affected more 6th-grade females. DISCUSSION: In schoolchildren of the public education system, myopia and myopic astigmatism > 3 dioptres tend to increase. The protective effect of natural light against myopia has been demonstrated in longitudinal and experimental studies. This evidence is to be considered in promoting children's time spent outdoors.

Enhanced recovery programmes after total hip arthroplasty can result in reduced length of hospital stay without compromising functional outcome.

AIMS: The primary aim of this study was to investigate the effect of an enhanced recovery program (ERP) on the short-term functional outcome after total hip arthroplasty (THA). Secondary outcomes included its effect on rates of dislocation and mortality. PATIENTS AND METHODS: Data were gathered on 1161 patients undergoing primary THA which included 611 patients treated with traditional rehabilitation and 550 treated with an ERP. RESULTS: The ERP was shown to be a significant independent factor which shortened length of stay (LOS) by a mean of 1.5 days (95% confidence interval (CI) 1.3 to 1.8, p < 0.001) after adjusting for confounding variables. The rates of dislocation (traditional 1.03% vs ERP 0.91%, p = 0.84) and mortality (1.5% vs 0.6%, p = 0.14) one year post-operatively were not significantly different. Both groups showed significant improvement in Harris Hip Score (42.8 vs 41.5) at 12 to 18 months post-operatively and there was no significant difference in the magnitude of improvement on univariate (p = 0.09) and multivariate analysis (p = 0.35). There was no significant difference in any of the eight domain scores of the Short-Form - 36 general health surveys post-operatively (p > 0.38). CONCLUSION: We conclude that an ERP after THA shortens LOS by a mean of 1.5 days and does not increase the rate of complications post-operatively. It gives equivalent functional outcomes to a traditional rehabilitation pathway. TAKE HOME MESSAGE: ERP reduces LOS after THA in comparison to traditional rehabilitation, without adversely affecting functional outcomes, dislocation rates or mortality.

A review of the surgical conversion rate and independent management of spinal extended scope practitioners in a secondary care setting.

INTRODUCTION: Spinal orthopaedic triage aims to reduce unnecessary referrals to surgical consultants, thereby reducing waiting times to be seen by a surgeon and to surgical intervention. This paper presents an evaluation of a spinal orthopaedic triage service in the third largest spinal unit in the UK. METHODS: A retrospective service evaluation spanning 2012 to 2014 was undertaken by members of the extended scope practitioner (ESP) team to evaluate the ESPs' ability to manage patient care independently and triage surgical referrals appropriately. Data collected included rates of independent management, referral rates for surgical consideration and conversion to surgery. Patient satisfaction rates were evaluated retrospectively from questionnaires given to 5% of discharged patients. RESULTS: A total of 2,651 patients were seen. The vast majority (92%) of all referrals seen by ESPs were managed independently. Only 8% required either a discussion with a surgeon to confirm management or for surgical review. Of the latter, 81% were considered to be suitable surgical referrals. A 99% satisfaction rate was reported by discharged patients. CONCLUSIONS: ESP services in a specialist spinal service are effective in managing spinal conditions conservatively and identifying surgical candidates appropriately. Further research is needed to confirm ESPs' diagnostic accuracy, patient outcomes and cost effectiveness.

Epidemiology of biopsy-proven giant cell arteritis in South Australia.

BACKGROUND/AIM: To determine the epidemiology and clinical features of biopsy-proven giant cell arteritis (GCA) in South Australia (SA). METHODS: Patients with biopsy-proven GCA were identified from pathology reports of temporal artery biopsies at SA Pathology laboratories, from 1 January 1992, to 31 July 2011. Epidemiological data were collected through patient questionnaires and standardised case note reviews. Incidence was estimated using Australian Bureau of Statistics population data for SA. Seasonality was analysed by Cosinor analysis, and time-to- event analysis was performed for the duration of steroid use. RESULTS: There were 314 cases of biopsy-proven GCA (72% female). The mean age at diagnosis of GCA was 78 years (interquartile range 72-82). The estimated population incidence for people over 50 was 3.2 per 100,000 person years. The female : male incidence ratio was 2.3 (P < 0.001), and incidence increased with each age decade. There was evidence of seasonal variation (P = 0.015), with higher rates observed in the summer months. Clinical data were available for 163 patients (68% female, median age 78 years). The most common presenting clinical features were temporal headache (74%), visual disturbance (68.4%), jaw claudication (59.3%) and symptoms of polymyalgia rheumatica (56%). The median initial steroid dose was 60 mg, with median duration of steroid use 4.5 years. Corticosteroid side-effects were common, affecting 89%, with 34% reporting five or more. CONCLUSIONS: This is the first epidemiological study of Australian biopsy-proven GCA patients. Age at onset and gender associations were similar to other Western populations. There was a high burden of steroid use in these patients.

Chromosomal aberrations in the peripheral blood of patients with metal-on-metal hip bearings.

BACKGROUND: Approximately one-third of patients undergoing joint replacement are under sixty years of age. Many of these patients may be exposed to wear debris from the orthopaedic implant for several decades. Clinical follow-up of this group of patients has been short compared with the lifetimes of the patients, and the long-term effects of this chronic exposure are unknown. METHODS: By using cytogenetic biomarkers (twenty-four-color fluorescent in situ hybridization [FISH]), we analyzed the peripheral blood leukocytes for chromosomal aberrations in three groups of subjects: (1) six age and sex-matched control subjects who had no implant and did not smoke (control group), (2) five subjects in whom an implant with a metal-on-metal articulation had been in situ for an average of thirty-five years (metal-on-metal group), and (3) four subjects in whom a metal-on-metal implant had been revised to a metal-on-polyethylene articulation at an average of twenty-two years (revised group). RESULTS: The number of chromosomal aberrations in the metal-on-metal group was greater than that in the control group. Specifically, the percentage of aneuploidy gain was three times greater (p = 0.01) in the metal-on-metal group. Structural aberrations were not seen in the control group, and this difference was highly significant (p = 0.003). Also, the number of chromosomal aberrations in the metal-on-metal group was greater than that in the revised group. Specifically, the percentage of structural aberrations was thirty-one-fold higher (p = 0.013). The percentage of aneuploidy gain in the metal-on-metal group was about twice that in the revised group, although this difference was not significant (p = 0.37). The percentage of aneuploidy gain in the revised group was about double that in the control group, although this difference was also not significant (p = 0.41). Translocations were seen only in subjects with a metal-on-metal articulation. CONCLUSIONS: The clinical consequences of the chromosomal changes seen in this study are unknown, and it is unknown if the changes are present in other cells in the body. The results emphasize the need for additional investigations into the effect of chronic exposure to elevated levels of metal ions produced by orthopaedic implants.

Measuring case-mix and outcome for older people in acute hospital care across Europe: the development and potential of the ACMEplus instrument.

AIM: To identify case-mix variables measured shortly after admission to be included in a patient classification system (ACMEplus) that best explains hospital outcome for older people in different health care systems. DESIGN: Observational prospective cohort study collecting patient factors (sociodemographics, functional, mental, clinical, administrative and perceived health) at different time assessments. METHODS: Multicentre study involving eight hospitals in six European countries (United Kingdom, Spain, Italy, Finland, Greece and Poland). It included consecutive patients aged 65 years or older admitted to hospital for acute medical problems. MAIN OUTCOME MEASURES: discharge status, hospital readmission, mortality and length of stay. RESULTS: Of the 1667 included patients (mean age = 78.1 years; male gender = 43.5%) two-third had at least one 'Geriatric Giant' (immobility, confusion, incontinence or falls) on admission or shortly after. The most frequently affected system was cardiovascular (29.2%) and 31% of patients declared poor or very poor health. Mean length of stay was 17.9 days, 79% of patients were discharged to their usual residence; in-hospital and 1-month follow up mortality were 7.4% and 11.6%, respectively. Physical function explained the highest variation (between 8% and 21%), followed by cognitive status and number of Geriatric Giants, for almost all outcomes except readmission. CONCLUSION: Factors other than diagnosis (physical function, cognition and presenting problems) are important in predicting key outcomes of acute hospital care for older people and are consistent across countries. Their inclusion in a standardized system of measurement may be a way of improving quality and equity of medical care in older people.

Massive endoprostheses for giant cell tumours of the distal femur: A 12-year follow-up.

We performed a retrospective analysis of twenty-five consecutive massive articulating endoprostheses that were inserted at our unit during the management of patients with Giant Cell Tumours of their distal femur. Fifteen of these implants were fixed hinge devices and ten were rotating hinge devices with HA collars (since 1993). None of these cases were revised for sepsis. There had been no cases of recurrent disease or amputation. The mean follow-up was 12 years (range = 5-18 years). The average age at time of insertion was 37 years. Young patients with fixed hinged devices developed a high incidence (33%) of aseptic loosening. They also had a significant rate of re-bushing. Results of the rotating hinge prosthesis with HA collar were much more promising. Functional scores were good after a period of 12 years despite the young age group.

Metal-on-metal joint arthroplasty: potential lifetime longevity.

We have studied a historical group of patients who underwent metal-on-metal hip arthroplasty more than 30 years ago. Those retaining their original metal-on-metal articulation (average follow-up 33 years) had an average Harris Hip Score of 75 (range 53-93) and an average Musculoskeletal Tumour Outcome Score of 75 (range 63-90). Those that have been revised (at an average of 22 years) maintain good functional outcome. The original implant is still in situ in five of the 11 survivors (follow-up 26-38 years). Retrieval analysis using a Mitutoya form tracer and an electron microscope demonstrated the self-polishing capacity of the metal-on-metal articulation. The surface roughness (Ra) of the worn articulating surface (Ra 0.05 mm) was smoother than that of the original unworn surface (Ra 0.32 mm). We believe our case series highlights the potential longevity of metal-on-metal articulation.

Metal ion levels after metal-on-metal proximal femoral replacements: a 30-year follow-up.

Metal-on-metal hip bearings are being implanted into younger patients. The consequence of elevated levels of potentially carcinogenic metal ions is therefore a cause for concern. We have determined the levels of cobalt (Co), chromium (Cr), titanium (Ti) and vanadium (Va) in the urine and whole blood of patients who had had metal-on-metal and metal-on-polyethylene articulations in situ for more than 30 years. We compared these with each other and with the levels for a control group of subjects. We found significantly elevated levels of whole blood Ti, Va and urinary Cr in all arthroplasty groups. The whole blood and urine levels of Co were grossly elevated, by a factor of 50 and 300 times respectively in patients with loose metal-on-metal articulations when compared with the control group. Stable metal-on-metal articulations showed much lower levels. Elevated levels of whole blood or urinary Co may be useful in identifying metal-on-metal articulations which are loose.

A customised replacement for polyostotic fibrous dysplasia of the upper femur. A 51-year follow-up.

We report the case of a 12-year-old boy with polyostotic fibrous dysplasia of the upper femur in whom a massive customised polyethylene prosthesis functioned successfully for more than fifty years.

Two contrasting presentations of localised pigmented villonodular synovitis of the knee.

Localised pigmented villonodular synovitis (LPNS) is a rare condition which most commonly affects the knee. We report two contrasting cases highlighting their different clinical presentations, investigations and subsequent treatments. Arthroscopic diagnosis was performed and used as a therapeutic tool. Pre-operative MRI was also an important contributor to diagnosis. LPNS should be included in the differential diagnosis of a young adult presenting with mechanical symptoms within the knee.

. . . and a time to die: the medicine of old age.

Most deaths in Britain occur in old age, and old people dying have as many symptoms as do the young. Management is complicated by diagnostic difficulty, by the frequency of mental disorder (sometimes treatable) and of severe disability, and by the difficulty in ascertaining patients' feelings. Decisions about the management of dying are inevitable, and multifactorial, and views of others may be helpful. Cardiopulmonary resuscitation is not indicated if futile, and may or may not be wanted by the patient. Withholding or withdrawing life-prolonging treatment may be justified if the totality of life gained (length and quality) is not justified by the burden of treatment. Decisions are most difficult when the prognosis is poor but not definitely fatal. Palliative care is important, not only in cancer. Euthanasia is seldom requested at present, and in The Netherlands is carried out less in old people than young. It would do little for the most serious problems of old age.

First steps in building ACME--an admission case-mix system for the elderly.

In the United Kingdom, specialists in Geriatric Medicine usually have a major role in treating acute medical problems of elderly people, in addition to running rehabilitation services and continuing care. The proportion of the different types of patients varies widely from service to service, however, making it difficult for clinicians to compare their performance with that of colleagues. Existing casemix measurement systems are usually designed to deal with a more homogeneous patient group (e.g. rehabilitation, long-stay care) and/or are too detailed for day-to-day use. We describe our attempts to devise a simple casemix system which would be of practical day-to-day use for individual specialists in Geriatric Medicine. We have classified patients according to (1) the acuteness and potential for recovery of their presenting illness and (2) their functional status (based on simple measures of mobility and cognitive impairment). These factors have been incorporated into a three-point score, CMIX, which was capable of explaining 19.5% of the variability in duration of stay in a prospective study of 400 new admissions in two centres. In contrast, age and sex explained only 1% of variability in these patients. The pattern of patient outcome also differed significantly between the three CMIX categories. We also propose a simple graphical method of classifying outcome which should prove useful for audit purposes even when our casemix system is not employed.