Outcomes following medial open reduction in infants aged ≤6 months with developmental dysplasia of the hip.

Aim: To evaluate mid-long term radiological outcomes following early medial approach open reduction (MAOR) performed for developmental dysplasia of the hip (DDH) in infants aged ≤6 months old at time of surgery, specifically incidence of clinically significant avascular necrosis (AVN), Severin outcomes and rates of further surgery. Methods: This is a single centre retrospective study of patients treated from 1999 to 2017. Only infants aged ≤6 months old at time of MAOR, and aged at least 6 years old at latest follow-up were included (minimum 5.5 years follow-up). Data was collected from electronic healthcare records and serial radiographs reviewed to assess outcomes. AVN was classified according to Kalamchi and MacEwen, with types 2-4 considered clinically significant. Severin classes I (excellent) and II (good) were considered satisfactory outcomes, and classes III + considered unsatisfactory. Results: MAOR was performed on 48 hips in 44 patients. Mean age at time of surgery was 4 months (SD 1.4, range 2-6), with mean follow-up of 9.8 years (SD 2.7, range 6.2-16.2). Clinically significant AVN developed in 9/48 hips (19 %), all of which were type 2. Only 1/48 hips (2 %) required a subsequent pelvic osteotomy due to residual dysplasia with subluxation at 2 years post MAOR. At final follow-up, 81 % of patients had excellent or good radiological outcomes (Severin I/II). No statistically significant predictors for developing AVN, including age and presence of ossific nucleus, were identified. Conclusion: Early MAOR in infants aged ≤6 months was associated with a very low rate of significant residual dysplasia requiring further surgery, yet was not associated with unacceptable rates or severe forms of AVN. We therefore recommend MAOR is performed early to optimise acetabular remodelling potential and minimise the need for concurrent or subsequent bony procedures.

Is bisphosphonate use a risk factor for atypical periprosthetic/peri-implant fractures? - A metanalysis of retrospective cohort studies and systematic review of the current evidence.

INTRODUCTION: Atypical periprosthetic/peri-implant fractures are not recognised in any widely used classification and therefore little focus is given to them. Multiple case reports and case series demonstrate these fractures exist and are related to bisphosphonate (BP) use. HYPOTHESIS: Are patients taking long-term BPs at an increased risk of developing an atypical periprosthetic/peri-implant fracture? Is a particular BP drug causing an increased risk of fracture? Is there a correlation between the time of BP use and the incidence of fractures? Do vitamin D analogues or parathyroid hormones reduce the time to union? MATERIAL AND METHODS: Systematic review of all available evidence on the existence of periprosthetic/peri-implant atypical fractures in patients taking long-term BPs and metanalysis of available retrospective cohort studies. Selected 1 systematic review, 7 retrospective cohort studies (5 used for metanalysis) and 32 case reports. RESULTS: Metanalysis reported a risk ratio of 14.1, p=0.25, suggesting bisphosphonates are a risk factor in the development of periprosthetic/peri-implant atypical fractures. The secondary outcomes couldn't be reliably identified due to the small size of available studies and risk of significant bias. DISCUSSION: Atypical periprosthetic/peri-implant fractures are an entity and seem to be associated with the use of bisphosphonates. The benefits of bisphosphonates use outweigh the risks, but clinicians should be aware of atypical fractures and actively search for them when patients on long-term bisphosphonates attend with non-specific pain close to the implant/prosthesis or reduced mobility. LEVEL OF EVIDENCE: II, Systematic review and metanalysis.

A Rare Case of a Fractured Exeter V40 Stem in Revision Hip Arthroplasty.

Introduction: The Exeter stem by Stryker is a polished, double wedge, tapered,and stainless steel cemented implant that is known to have high mechanical strength, and therefore can carry a significant load. Case Report: Due to the rare nature of fractures of this type of implant, its success and effectiveness within hip arthroplasty, the Exeter stem has become one of the most commonly used surgical treatment regimens for hip fractures. At present, there are only a handful of published papers detailing a fracture through an Exeter stem implant. Conclusion: The current case report documents a rare case of a fractured Exeter V40 stem and its subsequent treatment.

Rothia mucilaginosa: a case of septic arthritis in a native knee and review of the literature.

Rothia mucilaginosa is a Gram-positive aerobic coccus usually found in the oral and respiratory tract. Septic arthritis is an uncommon condition, but is an orthopaedic emergency. A rare case of knee septic arthritis due to R. mucilaginosa is presented. Patient management and outcomes are discussed, and learning points from this case are outlined to help manage any further cases that may arise.

Has the Bachelor of Surgery Left Medical School?-A National Undergraduate Assessment.

INTRODUCTION: Nearly all trainee doctors would undertake a surgical placement in their clinical training; however, there is anecdotal evidence of variability in undergraduate surgical teaching across the UK. We set out to describe the provision of undergraduate surgery and report graduating students' opinions of aspects of this. METHODS: We undertook a cross-sectional questionnaire of medical students graduating in 2014 from UK medical schools. An online electronic questionnaire was used to capture demographics, career intentions, and individual's undergraduate experience of surgery. A separate questionnaire was sent to medical schools to assess time devoted to surgical placements and how surgical sciences were taught and assessed. RESULTS: From 483 responses covering 31 UK medical schools, there were 328 completed student questionnaires. A third of respondents felt that teaching of surgical sciences was inadequate. Medical schools reported time allocated to surgical specialties ranging from 4 to 21 weeks (median 13 weeks). Among all, 1 medical school offered a basic surgical skills course and 1 medical school specifically assessed surgical-related skills. Overall, 65% of medical students felt prepared for a surgical foundation placement and 88% felt prepared for a medical foundation placement. In total, 78% felt ready to participate in an acute medicine on-call and 48% felt ready for emergency surgery on-call. There was a positive association between time dedicated to undergraduate surgery and reported preparedness for a foundation surgical job. CONCLUSIONS: UK medical students reported uniformly low rates of satisfaction with surgical science teaching. Students studying at medical schools with more time in the curriculum dedicated to surgery reported higher levels of preparedness for surgical foundation jobs. There were differences in the rates of perceived preparedness for surgical posts and for emergency surgery. There is a clear need to review undergraduate surgical provision to ensure that students are equipped for safe practice in junior surgical foundation jobs.

Congenital abnormalities of the urogenital tract: the clue is in the cord?

Congenital abnormalities of the female urogenital tract are not uncommon, with an estimated incidence of 2-4% across the female population. Within this population, up to 40% will have associated renal tract abnormalities. A previously well 12-year-old girl presented to the emergency department with abdominal pain, vomiting and a palpable pelvic mass. Ultrasound and MR scans were performed. The imaging revealed a didelphys uterus, an obstructed hemivagina and ipsilateral renal agenesis, characteristic of Herlyn-Werner-Wunderlich syndrome. The patient was noted at birth to have a single umbilical artery, which is associated with an increased risk of congenital abnormalities and useful information for the early identification of abnormalities that have implications for renal function and future fertility.