Clinical efficacy of the virtual fracture clinic: analysis of 17,269 referrals by type of injury.

INTRODUCTION: Numerous studies have deemed the virtual fracture clinic (VFC) model to be both cost and clinically effective. However, very few of these studies have analysed the type of injuries seen in the VFC. The objectives of this study were to assess the clinical effectiveness of the VFC and analyse the types of injuries that lead to patients re-presenting in the face-to-face fracture clinic after being discharged virtually. METHODS: This is a retrospective study analysing 17,269 patients referred to the VFC between September 2017 and February 2020. Data regarding the type of presenting injury were collected to understand which injuries required further management after being discharged virtually. Patient clinic letters provided data regarding the purpose and outcomes of VFC referrals as well as face-to-face appointments. Theatre lists were cross-referenced to extract data regarding surgical management. RESULTS: In total, 57.37% (9,908) patients were discharged virtually. Of these patients, 92.52% were discharged successfully and 7.48% re-presented to the fracture clinic: 98.11% were managed conservatively and 1.88% required surgery. The highest number of failed discharges were for distal radius fractures (109, 14.69%). Face-to-face follow-up in fracture clinic was requested for 37.06% (6,400) of patients; 4.98% of them required surgical intervention. Some 5.56% (961) of referrals were removed from our analysis: 807 were inappropriate referrals and 154 were deemed suitable for multidisciplinary team discussion. The trust has saved an average of £702,205 annually since introduction of the VFC. CONCLUSIONS: The VFC model delivers as promised in terms of clinical efficacy and cost management. Injury types showing higher numbers of unsuccessful discharges could benefit from having modified management pathways.

The safety and efficacy of day-case total joint arthroplasty.

INTRODUCTION: The popularity of day-case arthroplasty has been fuelled by focus on its cost effectiveness for the healthcare system. Safety concerns still remain. The aim of this review was to compare readmission rates after total joint arthroplasty for patients undergoing day-case surgery and for inpatients. METHODS: A comprehensive online search of databases was performed for all published articles in the English language evaluating readmission rates after total hip arthroplasty (THA) and total knee arthroplasty (TKA). Seventeen studies were deemed eligible and included in the meta-analysis. RESULTS: All studies included in the meta-analysis described readmission rates following THA/TKA. The readmission rate for day-case patients was 1.9% (n=124) whereas for inpatients, it was 2.0% (n=12,399). Compared with inpatient arthroplasty, day-case arthroplasty was associated with lower total readmission rates (odds ratio [OR]: 0.77, 95% confidence interval [CI]: 0.63-0.94, p=0.01). Furthermore, day-case surgery conferred a decrease in readmission rates for both THA (1.3% vs 7.0%) and TKA (2.7% vs 4.3%). Moreover, day-case THA and TKA were both associated with a decreased chance of readmission (OR: 0.27, 95% CI: 0.17-0.42, p<0.00001; and OR: 0.55, 95% CI: 0.42-0.72, p<0.00001 respectively). CONCLUSIONS: This review emphasises that with a thoughtful, designated protocol and with careful patient selection, day-case arthroplasty is a safe and effective option.

Ilizarov management of Schatzker IV to VI fractures of the tibial plateau: 105 fractures at a mean follow-up of 7.8 years.

This study aimed to determine the long-term functional, clinical and radiological outcomes in patients with Schatzker IV to VI fractures of the tibial plateau treated with an Ilizarov frame. Clinical, functional and radiological assessment was carried out at a minimum of one year post-operatively. A cohort of 105 patients (62 men, 43 women) with a mean age of 49 years (15 to 87) and a mean follow-up of 7.8 years (1 to 19) were reviewed. There were 18 type IV, 10 type V and 77 type VI fractures. All fractures united with a mean time to union of 20.1 weeks (10.6 to 42.3). No patient developed a deep infection. The median range of movement (ROM) of the knee was 110(°) and the median Iowa score was 85. Our study demonstrates good long-term functional outcome with no deep infection; spanning the knee had no detrimental effect on the ROM or functional outcome. High-energy fractures of the tibial plateau may be treated effectively with a fine wire Ilizarov fixator.

N-Acetyl cysteine blunts proteotoxicity in a heat shock protein-dependent manner.

N-Acetyl cysteine, a glutathione precursor, has been shown to benefit patients with Alzheimer's disease and reduce the symptoms of traumatic brain injury in soldiers. Parkinson's and Alzheimer's disease are both characterized by stress from protein misfolding, or proteotoxicity. We have developed a high-throughput model of proteotoxicity by treating neuroblastoma N2a cells with the proteasome inhibitor MG132 and performing three independent assays for viability. Our previous study showed that N-acetyl cysteine protects N2a cells against two sequential treatments of MG132 and raises glutathione levels in a two-hit model of synergistic neurodegeneration. In the present study, however, N-acetyl cysteine was found to reduce the toxicity of a single hit of MG132 independent of its effect on glutathione. All three viability assays confirmed this protection. We measured heat shock protein 70 (Hsp70) levels because Hsp70 is a protective chaperone that helps refold proteins or guides ubiquitinated proteins toward degradation by the proteasome. Hsp70 levels were higher in MG132-treated cells when N-acetyl cysteine was applied. No parallel change in heat shock cognate 70 (Hsc70) was elicited. Inhibition of Hsp70/Hsc70 activity with VER 155008 attenuated the protection afforded by N-acetyl cysteine in a dose-responsive manner. MG132 induced a large rise in ubiquitinated proteins and N-acetyl cysteine reduced this effect. Consistent with the chaperone functions of Hsp70, VER 155008 also prevented the reduction in ubiquitin-conjugated proteins by N-acetyl cysteine. These data reveal a new role for N-acetyl cysteine: this compound may reduce misfolded protein levels and ameliorate proteotoxicity through heat shock proteins. These findings broaden the potential mechanisms of action for this dietary supplement in neurodegenerative proteinopathies.

Variability in the presentation of synovial sarcoma in children: a plea for greater awareness.

We have analysed the pattern of symptoms in patients presenting with synovial sarcoma to identify factors which led to long delays in diagnosis. In 35 children, the early symptoms and the results of clinical and radiological investigation were reviewed, along with the presumed diagnoses. The duration of symptoms was separated into patient delay and doctor delay. Only half of the patients had one or more of the four clinical findings suggestive of sarcoma according to the guidance of the National Institute for Clinical Excellence at the onset of symptoms. Of the 33 children for whom data were available, 16 (48.5%) presented with a painless mass and in ten (30.3%) no mass was identified. Seven (21.2%) had an unexplained joint contracture. Many had been extensively investigated unsuccessfully. The mean duration of symptoms was 98 weeks (2 to 364), the mean patient delay was 43 weeks (0 to 156) and the mean doctor delay was 50 weeks (0 to 362). The mean number of doctors seen before referral was three (1 to 6) and for 15 patients the diagnosis was obtained after unplanned excision. Tumours around the knee and elbow were associated with a longer duration of symptoms and longer doctor delay compared with those at other sites. Delays did not improve significantly over the period of our study of 21 years, and we were unable to show that delay in diagnosis led to a worse prognosis. Our findings highlight the variety of symptoms associated with synovial sarcoma and encourage greater awareness of this tumour as a potential diagnosis in childhood.

Unique combination of patellofemoral joint arthroplasty with Osteochondral Autograft Transfer System (OATS) - a case series of six knees in five patients.

Patellofemoral arthroplasty (PFA) is an accepted procedure for the treatment of isolated patellofemoral osteoarthritis. However its failure rate has been attributed to progressive femorotibial arthritis. Autologous osteochondral transplantation is an established procedure for the repair of focal cartilaginous defects on the medial and lateral femoral condyles. We present our case series of six knees in five patients where we combined the two procedures and extended the indication for PFA and delayed the need for total knee arthroplasty (TKA) in all but one patient over a mean follow up period of 3.8 years.