Dedicated peri-operative pathway improved day case discharge rate for anterior cruciate ligament reconstructions.

The authors proposed that a well-developed peri-operative pathway for anterior cruciate ligament (ACL) reconstructions improve day case discharge rate with high patient satisfaction. A prospective observational study was undertaken at a district general hospital in UK between August 2017 and April 2018. A dedicated multidisciplinary peri-operative pathway was developed and introduced in January 2018. All primary ACL reconstructions using hamstring grafts in adult patients were included. Primary outcome measure was day case discharge and secondary outcome measures were visual analogue score for pain (VASP), nausea and vomiting scale (NVS), patient satisfaction and 30-day readmission. Patients who underwent surgery before and after introduction of the pathway were in group 1 and group 2, respectively. There were 19 and 22 patients each in group 1 and 2. Age and gender were similar in both groups. Day case discharge rate was significantly better in group 2 (68.4% vs 95.5%, p = 0.02). There were no significant differences in VASP or NVS on day 0, 1 or 3. Patient satisfaction rates were better in group 2 (85.7% vs 100%, p = 0.13). There were no readmissions in both groups. The VASP on day 1 and day 3 post-operatively was significantly better in those who were discharged on the same day (66.8 vs 41.3, p = 0.02; 60.5 vs 34.9, p = 0.03). A well-developed dedicated peri-operative pathway improved day case discharge rate for ACL reconstructions. The pathway was safe and had a higher patient satisfaction rate.

Maternal risk factors for singleton preterm births and survival at the University of Nigeria Teaching Hospital, Enugu, Nigeria.

CONTEXT: Risk factors for and survival of singleton preterm births may vary according to geographical locations because of socioeconomic differences and lifestyle. AIMS: The aim was to describe maternal risk factors and survival-to-discharge rate for singleton preterm births at the University of Nigeria Teaching Hospital and determine the relationship between maternal risk factors and the survival of singleton preterm babies. SUBJECTS AND METHODS: A comparative retrospective review of singleton preterm and term births from January 2009 to December 2013 was carried out. Statistical analysis involved descriptive and inferential statistics at 95% level of confidence using the Statistical Package for Social Sciences (SPSS) version 15 for Windows. P≤0.05 was considered significant. RESULTS: A total of 784 births including 392 singleton preterm births (aged 26-36+6) and 392 singleton term births were studied. The mean age of mothers who delivered singleton preterm babies did not differ significantly from that of mothers who delivered singleton term babies (30.2±4.9 years vs. 30.8±4.7; P=0.06). Lack of antenatal care (adjusted odds ratio [aOR]=2.63; 95% confidence interval [CI] 1.92, 6.07), Previous preterm birth (aOR=5.06; 95% CI: 2.66, 9.12), having pregnancy complications including antepartum hemorrhage, preeclampsia/eclampsia or premature rupture of membranes (aOR=5.12; 95% CI: 2.4, 11.8), being unmarried (aOR=2.41; 1.56, 3.71) and nulliparity (aOR=2.08, 95% CI: 1.22, 4.91) were independent risk factors for singleton preterm births. The average survival-to-discharge rate for preterm babies during the period was 38.4%. The mean duration of admission for singleton preterm babies was 16±5.8 days (range: 2-75 days). Whereas survival was dependent on, gestational age at birth (P<0.001) and mode of delivery (P=0.01), it was not dependent on maternal risk factors of parity, marital status, complications of pregnancy, and antenatal care. CONCLUSIONS: There was a low rate of survival of singleton preterm babies at the study center and survival was dependent on gestational age at birth and mode of delivery, but not on maternal sociodemographic risk factors for singleton preterm births. Active collaboration between the obstetrician and the neonatologist in deciding when and how to deliver these babies may provide improved chances of survival.

Which factors determine the wear rate of large-diameter metal-on-metal hip replacements? Multivariate analysis of two hundred and seventy-six components.

BACKGROUND: Determining the relationship between clinical factors and engineering analysis of retrieved hip implants can help our understanding of the mechanism of device failure. This is particularly important for metal-on-metal hip arthroplasties because the most common cause of failure is unexplained. We sought to understand the variation in wear rates in a large series of retrieved metal-on-metal hip arthroplasty components. METHODS: We prospectively recorded preoperative, intraoperative, and postoperative data to study the effect on both head and cup wear rates of the following variables: patient sex, cause of failure, manufacturer type, resurfacing or modular design, blood cobalt and chromium levels, edge-loading, femoral head size, and cup inclination angle. We analyzed 276 components (138 femoral head and acetabular cup couples) retrieved from failed metal-on-metal hip replacements. RESULTS: We found a high rate of edge-loading (64%), but only forty-three (31%) of 138 hips had a cup inclination angle of >55°. Multivariate analysis showed that the most important factor responsible for the variation in wear rate was the presence or absence of edge-loading, even when adjusted for cup inclination angle. Strong positive correlations were found between acetabular cup and femoral head wear rates and between wear rates and both blood cobalt and chromium ion levels. CONCLUSIONS: Multivariate analysis of nine factors found that edge-loading was the most important predictor of wear rate and occurred in two-thirds of failed metal-on-metal hip replacements. The majority did not have excessive cup inclination angles: 68% had an inclination angle of ≤55°. This finding, together with the relatively low median wear rate of the components in our study, suggests that cup position and/or wear rate may not be the only outcome related to failure of metal-on-metal hip replacements.

The relationship between the angle of version and rate of wear of retrieved metal-on-metal resurfacings: a prospective, CT-based study.

We measured the orientation of the acetabular and femoral components in 45 patients (33 men, 12 women) with a mean age of 53.4 years (30 to 74) who had undergone revision of metal-on-metal hip resurfacings. Three-dimensional CT was used to measure the inclination and version of the acetabular component, femoral version and the horizontal femoral offset, and the linear wear of the removed acetabular components was measured using a roundness machine. We found that acetabular version and combined version of the acetabular and femoral components were weakly positively correlated with the rate of wear. The acetabular inclination angle was strongly positively correlated with the rate of wear. Femoral version was weakly negatively correlated with the rate of wear. Application of a threshold of > 5 µm/year for the rate of wear in order to separate the revisions into low or high wearing groups showed that more high wearing components were implanted outside Lewinnek's safe zone, but that this was mainly due to the inclination of the acetabular component, which was the only parameter that significantly differed between the groups. We were unable to show that excess version of the acetabular component alone or combined with femoral version was associated with an increase in the rate of wear based on our assessment of version using CT.

Retrieval analysis of 240 metal-on-metal hip components, comparing modular total hip replacement with hip resurfacing.

This study compared component wear rates and pre-revision blood metal ions levels in two groups of failed metal-on-metal hip arthroplasties: hip resurfacing and modular total hip replacement (THR). There was no significant difference in the median rate of linear wear between the groups for both acetabular (p = 0.4633) and femoral (p = 0.0872) components. There was also no significant difference in the median linear wear rates when failed hip resurfacing and modular THR hips of the same type (ASR and Birmingham hip resurfacing (BHR)) were compared. Unlike other studies of well-functioning hips, there was no significant difference in pre-revision blood metal ion levels between hip resurfacing and modular THR. Edge loading was common in both groups, but more common in the resurfacing group (67%) than in the modular group (57%). However, this was not significant (p = 0.3479). We attribute this difference to retention of the neck in resurfacing of the hip, leading to impingement-type edge loading. This was supported by visual evidence of impingement on the femur. These findings show that failed metal-on-metal hip resurfacing and modular THRs have similar component wear rates and are both associated with raised pre-revision blood levels of metal ions.

[A case of acute suppurative thyroiditis associated with thyroid papillary carcinoma].

A sixty-one-year-old female was admitted to our hospital in October 1988 because of fever and a right neck mass associated with redness and tenderness. The size of the thyroid mass had gradually increased over 3 months. Two masses were detected in the thyroid by ultrasonography and MRI. She has positive thyroid autoantibodies, high CRP levels and high erythrocyte sedimentation rates. While she had normal white blood cell counts, massive neutrophils were obtained from her thyroid mass by aspiration biopsy, indicating acute suppurative thyroiditis. However, we could not find any bacteria to cause suppurative thyroiditis either in the blood or in thyroid aspirates. Serum levels of thyroid hormone were slightly elevated but she did not complain of any thyrotoxic symptoms. Radioactive iodine uptake (RAIU) of the thyroid gland was markedly decreased (2%/24h). Following treatment with antibiotics, her inflammation and symptoms immediately improved, and pus spontaneously ran from the collapsed thyroid mass. Then serum thyroid hormone levels and RAIU were normalized and the right thyroid mass disappeared. She was discharged in December 1988. There were no signs of recurrence of suppurative thyroiditis until now. She received a pharyngo-esophageal barium examination in search of the route of infection 4 times, but no fistula was revealed. However, as her left thyroid mass consistently remained thereafter, an operation of the left thyroid mass was performed in December 1989. The histologic examination of the resected thyroid revealed the coexistence of encapsulated follicular adenoma, minute papillary carcinoma and chronic thyroiditis. There are few reports of such a case having a combination of suppurative thyroiditis, thyroid cancer and chronic thyroiditis observed in an elderly female.