Emergency Department closed reduction of dislocated THR: the REDDTHR Prospective Multi-centre Study.

INTRODUCTION: Dislocation is a potentially devastating complication severely affecting outcomes post total hip arthroplasty (THR). We aimed to assess the efficacy and safety of closed reduction of a dislocated THR within the Emergency Department (ED). METHODS: A prospective multi-centre study was conducted over a 1-year period from November 2020 to December 2021 within 10 hospitals based in the East of England. Collected data included patient demographics, agent used for sedation, hospital length of stay, implant type and discharge destination. Patients were analysed according to whether successful reduction was performed in the ED or not. The primary outcome was length of stay, with secondary outcomes including discharge destination and pain post-procedure. RESULTS: We studied 99 patients with an average age of 77.02 years, with 39 (39%) patients being male. 11 patients had revision hip replacements and 88 patients had primary THRs. 57 (57.6%) underwent closed reduction in the Emergency department, of which 44 (77.2%) were successful. Successful closed reduction was significantly associated with lower patient age (p = 0.02), lower American society of Anesthesiologists (ASA) score (p < 0.01) and use of propofol (p < 0.01). Patients who underwent successful ED closed reduction had a lower hospital stay than those that did not (1 vs. 3 days, p < 0.01), however there was no significant difference in discharge destination. CONCLUSIONS: When adopted, success following closed reduction is increased in younger patients with less comorbidities following use of propofol sedation. Following sedation, patients have a significantly shorter hospital stay. Increasing uptake of closed reduction of THR dislocation within the ED in suitable patients with evidence-based best practice protocols will maximise patient outcomes whilst allowing efficient resource utilisation.

Anatomic Total Shoulder Arthroplasty Versus Reverse Total Shoulder Arthroplasty in Patients Aged Over 70 Without a Full-Thickness Rotator Cuff Tear: A Systematic Review and Meta-Analysis.

Introduction: This systematic review and meta-analysis compared the revision rates, complications, and outcomes in anatomic total shoulder arthroplasty (aTSA) and reverse TSA (rTSA) performed for primary glenohumeral osteoarthritis in patients aged over 70 years without a full-thickness rotator cuff tear. Materials and Methods: We performed a systematic literature search identifying comparative studies meeting the above patient criteria and published from January 2010 to May 2022 from 3 databases: MEDLINE, EMBASE, and Cochrane Library. We performed the systematic review in accordance with PRISMA guidelines and the study was prospectively registered on PROSPERO. Results: From the 1798 studies identified from the initial literature search, 4 met our inclusion criteria. Two thousand seven hundred thirty-one shoulder arthroplasties (1472 aTSA and 1259 rTSA) were evaluated with a minimum follow up of 2 years. A statistically significant lower revision rate was observed in rTSA compared to aTSA (odds ratio [OR] 0.50, 95% confidence interval [CI]: 0.30, 0.84, p < .05). No significant difference was noted between aTSA and rTSA in overall complication rate (OR 0.98, 95% CI 0.34, 2.86, p = .97) while aTSA displayed a statistically significant improved postoperative Constant-Murley score [aTSA: 80(75; 82), rTSA: 68(66; 76.5), p < .001]. Conclusion: Higher revision rates were identified following aTSA in our study population, although admittedly this is within retrospective studies. aTSA displayed equal functional results and postoperative complications compared to rTSA in patients over 70 without a full-thickness rotator cuff tear. Given these similar results a shoulder surgeon must carefully consider each patient individually prior to deciding the optimal form of arthroplasty to offer.

Dual Mobility Total Hip Replacements in Young Patients- A Systematic Review.

Background: There is little consensus on outcomes of dual Mobility total hip replacement (DM-THR) in younger patients. We performed a systematic review to examine this. Methods: A systematic review of all observational studies and randomised controlled trials of patients under 70 with primary DM-THR in MEDLINE, EMBASE, Pubmed, Cochrane was performed according to PRISMA guidelines. Collected data included demographics, revision, dislocation and infection rates and functional scores. Results: Twelve papers studying 738 DM-THR in 664 patients were included. The mean patient age was 46.9 years (13.5-69.0), with 319 (48.0%) being female and 419 (52.0%) being male. After an average follow-up of 90.0 months (1-371 months), the revision rate was 12.7% (84 hips), 0 dislocations were reported but 2.5% (15 hips) underwent intra-prosthetic dislocation. 32.1% hip revisions were due to aseptic loosening. Conclusion: Limited literature surrounding the use of DM-THR suggests favourable stability but higher revision rates than conventional THR.

Paediatric talus fractures: A guide to management based on a review of the literature.

BACKGROUND: Talus fractures are devastating injuries in both adults and children. Well recognised complications such as avascular necrosis (AVN), post-traumatic arthritis and non-union contribute to patient morbidity. This systematic review aimed to assess the literature on these injuries in children and their associated incidence, classification, management and outcome. METHODS: A systematic review of Embase and Medline databases was carried out in accordance with PRISMA guidelines. Inclusion criteria were clinically orientated studies looking at talus fractures in paediatric patients (less than 18 years old). Exclusion criteria were conference abstracts, opinion-based reports, articles not published in English and articles published prior to 1980. Data extracted included patient demographics, fracture classification, management and outcomes. RESULTS: 31 studies were included encompassing 143 patients and 167 fractures with a mean age of 11.9 years (1.2-18). The majority of fractures (43.7%, n = 73) were of the talar neck. 70.6% (n = 101) were managed operatively. The overall rate of AVN was 15.4% (n = 22), with a 96.5% union rate. Observed rates of AVN were 5.7% in Hawkin's 1, 11.8% in Hawkin's 2, 53.3% in Hawkin's 3 and 0 in Hawkin's 4 injuries. All cases of non-union occurred in children over 12 years, and seven children required arthrodesis (1x pantalar, 1x subtalar and 5x subtalar and tibiotalar) with a mean age of 14.4 years (9-17). CONCLUSIONS: Talus fractures are rare but potentially devastating injuries in children. This systematic review has shown comparable rates of AVN in children to their adult counterparts, with higher rates of non-union and arthrodesis in adolescent patients. A lower threshold for operative intervention to achieve anatomical reduction in these patients should be considered.

Trauma epidemiology after easing of lockdown restrictions: experience from a level-one major trauma centre in England.

PURPOSE: The COVID-19 pandemic transformed the delivery of trauma care. We examined the effect of lockdown easing on trauma presentation and management from one Major Trauma Centre (MTC). METHODS: Data was retrospectively analysed from Trauma Audit and Research Network (TARN) on patients presenting to our MTC with trauma. The first 47 days of lockdown (23rd March-9th May 2020, period 1) were compared with the next 47 (10th May-26th June 2020, period 2) and last (27th June-13th August 2020, period 3). Data collected included demographics, mechanism and severity of injury, management and length of stay. RESULTS: 1249 patients were included; 62.2% were male with a mean age of 57.73. Footfall declined in April 2020 compared with 2019 (56 vs. 143) but rebounded by May (123 vs. 120 patients). Road traffic collisions increased over periods one-three (18.8% vs. 23% vs. 30.1%, p = 0.038); deliberate self-harm (DSH) increased in period two compared with one and three (6.3% vs. 3.4% vs. 1.4%, p = 0.03), respectively. When compared with 2019, the 2020 patient age was lower, with less trauma relating to alcohol (7.3% vs. 13.2%, p = 0.009), but more from DSH (3.6% vs. 2.1%, p = 0.10). In 2020 less patients were assessed by a consultant and trauma team, with a shorter stay in hospital and critical care. CONCLUSION: This is the first study to document trauma trends through a lockdown and thereafter. After lockdown easing, trauma footfall rapidly rebounded to 2019 levels. This should be acknowledged in resource allocation decisions if future lockdowns are necessitated.

Patient radiation exposure for endovascular deep venous interventions.

OBJECTIVE: The study aimed to assess the cumulative radiation exposure from preoperative, periprocedural, and follow-up imaging to patients who underwent common endovascular deep venous interventions for acute and chronic central venous outflow obstructive diseases; namely, deep vein thrombosis (DVT) thrombolysis, unilateral chronic iliofemoral venous stenting, and inferior vena cava (IVC) reconstruction in a single center. METHODS: Patients who had DVT thrombolysis of upper extremity (UE) DVT and lower extremity (LE) DVT, unilateral chronic iliofemoral venous stenting, and endovascular IVC reconstruction between May 1, 2012, and July 31, 2017, in a single unit were retrospectively reviewed. Demographic data, anatomic DVT, imaging, technical details of the index procedure, follow-up, and radiation exposure measured in dose-length product, dose-area product (DAP), and fluoroscopy time (FT) from related computed tomography scans and interventions were analyzed. Mann-Whitney U tests were performed to assess for significance of differences between subgroups. A P value of less than .05 was considered significant. RESULTS: In total, 20 UE DVT thrombolysis, 91 LE DVT thrombolysis, 56 unilateral chronic iliofemoral venous stenting, and 39 endovascular IVC reconstruction patients were included in the study, with the following median ages: 39 years (range, 20-67 years), 44 years (range, 15-78 years), 45 years (range, 20-80 years), and 35 years (range, 18 -73 years), respectively. The median cumulative DAP for the index DVT thrombolysis was 9.2 Gycm2 (range, 0.2-176.0 Gycm2) for LE DVT and 2.0 Gycm2 (range, 0.1-11.7 Gycm2) for UE DVT (P < .0001). The median cumulative FT for the index thrombolysis was 981 seconds (range, 20-4890 seconds) and 837 seconds (range, 19-2895 seconds) for LE DVT and UE DVT, respectively (P = .18). For unilateral chronic iliofemoral venous stenting, the median cumulative DAP and FT were 32.4 Gycm2 (range, 0.1-289.6 Gycm2) and 660 seconds (range, 246-4200 seconds), respectively. Meanwhile, the median cumulative DAP and FT for the endovascular IVC reconstruction were 60.8 Gycm2 (range, 2.5-269.1 Gycm2) and 2846 seconds (range, 836-11682 seconds), respectively. The median DAP for secondary procedures during follow-up was 6.6 Gycm2 (range, 0.8 186.5 Gycm2), 1.9 Gycm2 (range, 0.2-111.7 Gycm2), and 24.3 Gycm2 (range, 0.2-157.5 Gycm2) for LE DVT thrombolysis, unilateral chronic iliofemoral venous stenting, and endovascular IVC reconstruction, respectively. CONCLUSIONS: Patient radiation exposure for endovascular deep venous interventions for central venous outflow obstruction measured in DAP and FT seemed to be less than and at most similar to anatomically comparable arterial interventions in the literature. However, these patients were usually much younger than those with arterial diseases and may need secondary interventions involving further radiation exposure in their lifetime.