bluuebunny/crossref_metadata_2025 huggingface dataset:
Quality of Dying and Death of Patients With Cancer in Hospice Care in Uganda
Authors: Mah Kenneth , Namisango Eve , Luyirika Emmanuel , Ntizimira Christian , Hales Sarah , Zimmermann Camilla , Malfitano Carmine , Tilly Alyssa , Wolofsky Kayla , Rodin Gary
Published: February 2023

PURPOSE

Despite advances in palliative care in Uganda, there has been relatively little recent patient-centered research investigating end-of-life outcomes in this region. We assessed the quality of dying and death of patients with cancer in hospice care in Uganda.

METHODS

Bereaved caregivers of patients who received hospice care in Uganda and died 2-12 months earlier (N = 201) completed the Quality of Dying and Death Questionnaire, which includes 31 items and single-item ratings of overall quality of dying and moment of death, and the FAMCARE measure of family satisfaction with cancer care.

RESULTS

Caregivers reported low-intermediate overall quality of dying (mean [M] standard deviation [SD], 3.25 [2.98]) and overall quality of moment of death (M [SD], 3.59 [3.51]), with 47.0% of the ratings of these two outcomes in the poor range, but the mean family satisfaction with care was high (M [SD], 77.75 [10.26]). Most Quality of Dying and Death Questionnaire items (74.2%) were rated within the intermediate range. Items rated within the good range were religious-spiritual, interpersonal, and personal facets; two items within the poor range reflected physical functioning. Overall quality of dying was most strongly correlated with pain control (Spearman's rho [rs] = 0.45, P < .001), and overall quality of moment of death with state of consciousness before death and being unafraid of dying (rs = 0.42, P < .001). The FAMCARE score was not correlated with overall quality of dying or moment of death ( P = .576-.813). Only one FAMCARE item, information on managing patient's pain, was correlated with overall quality of moment of death (rs = –0.19, P = .008).

CONCLUSION

End-of-life care in hospices in Uganda requires further improvement, particularly with regard to symptom control. Patient-centered data could bolster advocacy efforts to support quality improvement of palliative care in this and other countries.
Fertility Preservation Practices at Pediatric Oncology Institutions in the United States: A Report From the Children's Oncology Group
Authors: Frederick Natasha N. , Klosky James L. , Meacham Lillian , Quinn Gwendolyn P. , Kelvin Joanne F. , Cherven Brooke , Freyer David R. , Dvorak Christopher C. , Brackett Julienne , Ahmed-Winston Sameeya , Bryson Elyse , Su H. Irene , Chow Eric J. , Levine Jennifer
Published: February 2023

PURPOSE:

Fertility discussions are an integral part of comprehensive care for pediatric, adolescent, and young adult patients newly diagnosed with cancer and are supported by national guidelines. Current institutional practices are poorly understood.

METHODS:

A cross-sectional survey was distributed to 220 Children's Oncology Group member institutions regarding fertility discussion practices. Descriptive statistics were calculated for all variables. The association between specific practices and selected outcomes on the basis of sex was examined via multivariable logistic regression.

RESULTS:

One hundred forty-four programs (65.5%) returned surveys. Of these, 65 (45.1%) reported routine discussions of fertility with all female patients and 55 (38.5%) all male patients ( P = .25). Ninety-two (63.8%) reported no specific criteria for offering females fertility preservation (FP), compared with 40 (27.7%) for males ( P < .001). Program characteristics associated with fertility discussions included reproductive endocrinology and infertility on site (females odds ratio [OR], 2.1; 95% CI, 1.0 to 4.3), discussion documentation mandate (females OR, 2.3; 95% CI, 1.0 to 5.5; males OR, 3.5; 95% CI, 1.4 to 8.7), and cumulative institution-based FP infrastructure (which included [1] routine practice of documentation, [2] template for documentation, [3] mandate for documentation, and [4] availability of FP navigation; females OR, 1.6; 95% CI, 1.1 to 2.3; males OR, 2.3; 95% CI, 1.6 to 3.4). Utilization of practices unsupported by guidelines included offering sperm banking after treatment initiation (39/135 programs; 28.9%), gonadotropin-releasing hormone analogs for ovarian suppression/FP (75/144 programs; 52.1%), ovarian tissue cryopreservation at diagnosis for patients with leukemia (19/64 programs; 29.7%), and testicular tissue cryopreservation (23/138 programs; 16.7%) not part of a clinical trial.

CONCLUSION:

Despite recommended guidelines, fertility discussions with patients/families before treatment initiation are not routine at Children's Oncology Group institutions. Standard criteria to determine which options should be offered to patients are more common for males than females.
Awake Surgery for a Patient With Glioblastoma and Severe Aphasia: Case Report
Authors: Kawauchi Daisuke , Matsuoka Aiko , Ohno Makoto , Miyakita Yasuji , Takahashi Masamichi , Yanagisawa Shunsuke , Tamura Yukie , Kikuchi Miyu , Naka Takahiro , Sato Tetsufumi , Narita Yoshitaka
Published: February 2023

BACKGROUND AND IMPORTANCE:

Patients with severe aphasia rarely become candidates for awake surgery because the intraoperative tasks of awake surgery for patients with aphasia have not been established.

CLINICAL PRESENTATION:

A 50-year-old, right-handed woman presented with recurrent glioblastoma invading her left superior temporal gyrus and inferior parietal lobule. She had severe aphasia, as she could barely verbalize her own name. However, we noticed that she could sing nursery rhymes with simple melodies and applied her singing ability as an axis of awake surgery. During awake surgery, she continuously sang simple songs to detect language dysfunction. As a result, 90% of the tumor was resected, preserving her language function and allowing for improvement. She was discharged 9 days after surgery without further neurological deterioration.

CONCLUSION:

Awake surgery is usually not indicated in patients with severe aphasia. However, for patients with aphasia who retain the ability to sing, intraoperative singing could be a possible alternative to maximize tumor resection while minimizing neurological dysfunction.
Directoras contemporáneas de cine español. De la A a la Z
Authors: Núñez Domínguez Trinidad , Vera Balanza Teresa
Published: February 2023

En el ámbito cinematográfico, son muchas las mujeres que, tanto en su labor a cargo de la dirección de largometrajes como en la elaboración de guiones, han demostrado solvente capacidad y competencia para constituirse en referentes dentro del sector. A pesar de ello, es habitual que pasen desapercibidas para los estudiantes de comunicación audiovisual y para el público en general. Con el objetivo de darlas a conocer, esta obra reúne la producción de las directoras de cine español contemporáneas cuyos largometrajes han sido exhibidos en salas comerciales desde el año 2000 al 2020, periodo en el que han narrado lo que significa la familia, la maternidad, el sentido de la amistad o de la sexualidad y situaciones sociopolítico-represivas. De esta manera, no solo se reivindica la calidad de sus obras, muchas de ellas reconocidas y premiadas, sino que también se subrayan las dificultades y barreras a las que se han visto sometidas en una industria cinematográfica que aspira a ser más plural, enriquecedora y diversa.
Being curious
Authors: Goldenberg Gemma
Published: February 2023

Internationally renowned centre Pen Green has a model of research-led practice with practitioners leading the way. By Gemma Goldenberg
Well read
Authors: Weinstein Nicole
Published: February 2023

Nicole Weinstein looks at the English Hubs programme, which is currently seeing more than 1,000 schools across the country receive intensive support for their teaching of reading to Reception and Year 1 children
Would GP charges help save the NHS?
Authors: Moffat Polly
Published: February 2023

A former health secretary has suggested that, to secure its future, the NHS must look at new ways to meet rising demand and move away from the free at point of use model. Is charging patients to see their GP part of the answer?
Supporting patients with obesity
Authors: Lay Sinead , Birch Rachel
Published: February 2023

Sinead Lay and Dr Rachel Birch at Medical Protection discuss how the whole practice team can play a role in ensuring patients with obesity feel comfortable and supported
Understanding the complexities of operational technology security
Authors: Escobar Eric
Published: February 2023

Many of the computer systems and networks most essential to our daily lives are invisible. They manage crucial infrastructure on which society depends. And yet many of these systems are surprisingly difficult to protect. Securing industrial control system (ICS) solutions and operational technology (OT) networks requires different approaches and tools compared to most conventional technology.
The perfect cyber storm – security budgets, skills shortages and automated attacks
Authors: Robinson Phil
Published: February 2023

A combination of economic pressures, sophisticated assaults that maximise returns and a shortage of skilled professionals now mean that businesses can expect to become increasingly vulnerable to attack as they enter 2023.
The Kangaroo Route
Authors: Sampson Ben
Published: February 2023

The latest Boeing Dreamliner is flying non-stop from the UK to Sydney, Australia in 19 hours. The route has always been a showcase for aeronautical innovation, including the revolutionary Lockheed Constellation 75 years ago
Flying at the Edge
Authors: Roper Jack
Published: February 2023

The first steps into the stratosphere are being taken by several projects around the world
The Explanatory Power of Intercultural Communicative Competence among EFL Teacher Candidates
Authors: EREN Ömer
Published: February 2023

While intercultural communicative competence has gained considerable attention in teachers’ professional development, contributions from teacher candidates have usually been underestimated. The traditional bound between language and culture has become less solid thanks to the advancements in transfer of languages and people, which has created a significant need to use language properly in international encounters. Therefore, acknowledging cultural values of different nations has become a primary aim while learning a foreign language. Teacher candidates could benefit from demanded intercultural skills and these skills have the potential to enrich their identity in social, academic, and professional lives. The current study intends to explain whether demographic variables of gender, study year, bi/multilingualism, living in another city, and study abroad experience have a predictive power on intercultural communicative competence. Several multiple regressions were used to analyse 199 teacher candidates’ previous intercultural experiences and findings suggest that number of languages explained the variance in intercultural communicative competence, and compared to bilingual individuals, multilinguals had higher intercultural communicative competence. Study abroad experience and living in another city also predicted the variance. However, gender difference did not yield significant results.
SILVER-COATED MEGAPROSTHESES IN RECONSTRUCTION FOR ORTHOPAEDIC ONCOLOGY AND BONE LOSS
Authors: Sundaram A. , Hockley E. , Hardy T. , Carey Smith R.L.
Published: February 2023

Rates of prosthetic joint infection in megaprostheses are high. The application of silver ion coating to implants serves as a deterrent to infection and biofilm formation.

A retrospective review was performed of all silver-coated MUTARS endoprosthetic reconstructions (SC-EPR) by a single Orthopaedic Oncology Surgeon. We examined the rate of component revision due to infection and the rate of infection successfully treated with antibiotic therapy. We reviewed overall revision rates, sub-categorised into the Henderson groupings for endoprosthesis modes of failure (Type 1 soft tissue failure, Type 2 aseptic loosening, Type 3 Structural failure, Type 4 Infection, Type 5 tumour progression).

283 silver-coated MUTARS endoprosthetic reconstructions were performed for 229 patients from October 2012 to July 2022. The average age at time of surgery was 58.9 years and 53% of our cohort were males. 154 (71.3%) patients underwent SC-EPR for oncological reconstruction and 32 (14.8%) for reconstruction for bone loss following prosthetic joint infection(s). Proximal femur SC-EPR (82) and distal femur (90) were the most common procedures. This cohort had an overall revision rate of 21.2% (60/283 cases). Component revisions were most commonly due to Type 4 infection (19 cases), Type 2 aseptic loosening/culture negative disease (15 cases), and Type 1 dislocation/soft tissue (12 cases).

Component revision rate for infection was 6.7% (19 cases). 15 underwent exchange of implants and 4 underwent transfemoral amputation due to recalcitrant infection and failure of soft tissue coverage. This equates to a limb salvage rate of 98.3%. The most common causative organisms remain staphylococcus species (47%) and polymicrobial infections (40%).

We expand on the existing literature advocating for the use of silver-coated endoprosthetic reconstructions. We provide insights from the vast experience of a single surgeon when addressing patients with oncological and bone loss-related complex reconstruction problems.
DAY-CASE TOTAL HIP ARTHROPLASTY PATHWAY USING THE POSTERIOR APPROACH
Authors: Brennan A. , Doran C. , Cashman J.
Published: February 2023

As Total Hip Replacement (THR) rates increase healthcare providers have sought to reduce costs, while at the same time improving patient safety and satisfaction. Up to 50% of patients may be appropriate for Day Case THR, and in appropriately selected patients’ studies show no increase in complication rate while affording a significant cost saving and maintaining a high rate of patient satisfaction.

Despite the potential benefits, levels of adoption of Day Case THR vary. A common cause for this is the perception that doing so would require the adoption of new surgical techniques, implants, or theatre equipment. We report on a Day-Case THR pathway in centres with an established and well-functioning Enhanced Recovery pathway, utilising the posterior approach and standard implants and positioning.

We prospectively collected the data on consecutive THRs performed by a single surgeon between June 2018 and July 2021. A standardised anaesthetic regimen using short acting spinal was used. Surgical data included approach, implants, operative time, and estimated blood loss. Outcome data included time of discharge from hospital, post operative complications, readmissions, and unscheduled health service attendance.

Data was gathered on 120 consecutive DCTHRs in 114 patients. 93% of patients were successfully discharged on the day of surgery. Four patients required re-admission: one infection treated with DAIR, one dislocation, one wound ooze admitted for a day of monitoring, one gastric ulcer. One patient had a short ED attendance for hypertension.

Our incidence of infection, dislocation and wound problems were similar to those seen in inpatient THR. Out data show that the widely used posterior approach using standard positioning and implants can be used effectively in a Day Case THR pathway, with no increase in failure of same-day discharge or re-admission to hospital.
SIMPLE TRAPEZIECTOMY VERSUS TRAPEZIECTOMY WITH FLEXOR CARPI RADIALIS SUSPENSION: A 17-YEAR FOLLOW-UP OF A RANDOMIZED BLIND TRIAL
Authors: Brennan A. , Blackburn J. , Thompson J. , Field J.
Published: February 2023

Thumb carpometacarpal joint (CMCJ) arthritis is a common and debilitating condition. The mainstay of surgical management is Trapeziectomy. Concerns about possible functional implications of collapse of the metacarpal into the arthroplasty space as well as the potential for scaphometacarpal led to the development of techniques to try and prevent this. The purpose of this study was to investigate if there were any significant differences in the long-term outcomes of patients who participated in a randomized trial of trapeziectomy alone compared with trapeziectomy with ligament reconstruction and tendon interposition (LRTI).

Sixty-five patients participated in our original trial, the 1 year findings of which were published in 2007. These patients were invited for a follow-up visit at a mean of 17 years (range 15–20) postoperatively. Twenty-eight patients attended, who had 34 operations, 14 trapeziectomy alone and 20 with LRTI. Patients were asked to complete a visual analogue scale (VAS) for satisfaction with the outcome of their procedure, rated on a scale from 0 (most dissatisfied) to 100 (most satisfied). They also completed the short version of the Disabilities of the Arm, Shoulder and Hand Score (QuickDASH) at their appointment. They underwent a functional assessment with a hand therapist and had a radiograph of the thumb.

There were no statistically significant differences between the two groups in terms of satisfaction with surgery or functional outcomes, with most measurements showing minimal or no differences in means between the two groups. There was no difference in the space between the metacarpal and scaphoid on radiograph. Radial abduction was the only parameter that was significantly greater in the patients with simple trapeziectomy (median 79°) compared with trapeziectomy with LRTI (median 71°) (p = 0.04). Even at 17 years there is no significant benefit of LRTI over trapeziectomy alone for thumb carpometacarpal joint osteoarthritis.
USE OF A MODIFIED CLAVIEN-DINDO CLASSIFICATION SYSTEM FOR ORTHOPAEDIC COMPLICATIONS IN A LEVEL 1 TRAUMA CENTRE
Authors: Talia A.J. , Furness N. , Liew S.M.
Published: February 2023

Complications are an inevitable part of orthopaedic surgery, how one defines complications can have an impact on the ability to learn from them. A group of general surgeons headed by Clavien and Dindo et al.1 have previously published their classification system for surgical complications based on the type of therapy required to correct the complication.

Our aim was to evaluate a modification of this classification system and its use over a 12-month period at our institution via our departmental audits, our hypothesis being that this would direct appropriate discussion around our complications and hence learning and institutional change.

A modified Clavien-Dindo Classification was prospectively applied to all complications recorded in the Orthopaedic departmental quarterly audits at our institution for a 12-month period (4 audits). The audit discussion was recorded and analysed and compared with the quarterly complication audits for the preceding 12-month period.

The modified Clavien-Dindo classification for surgical complications was applicable and reproducible to Orthopaedic complications in our level 1 trauma centre. It is a transparent system, objective in its interpretation and avoids the tendency to down-grade serious complications. It was easy to apply and directed discussion appropriately at our quarterly audit meetings on complications where there was a preventable outcome or important learning point. In particular modifications to VTE and Death classes allowed the unit to focus discussion on cases where complication was preventable or unexpected.

The modified Clavien-Dindo classification system is an easy to use and reproducible classification system for Orthopaedic complications in our unit it directed audit discussion towards cases where complications were preventable or had a learning point.
LONG-TERM RESULTS OF A NEW ROTATING HINGE KNEE IMPLANT: A MINIMUM SEVEN-YEAR FOLLOW-UP
Authors: Vertesich K. , Staats K. , Böhler Ch. , Koza R. , Lass R. , Giurea A.
Published: February 2023

The use of rotating hinge (RH) prostheses for severe primary as well as revision arthroplasty is widely established. Aim of this study was to investigate long term results of a new RH prosthesis (EnduRo®, B Braun, Germany), which uses carbon-fiber reinforced poly-ether-ether-ketone (CFR PEEK) as a new bearing material, first time used in knee arthroplasty.

Fifty-six consecutive patients, who received the EnduRo® RH prosthesis were included in this prospective study: 21 patients (37.5%) received the prosthesis as a primary total knee arthroplasty (TKA) and 35 patients (62.5%) underwent revision total knee arthroplasties (rTKA). Clinical and radiographic examinations were performed preoperatively as well as postoperatively after 3 and 12 months and annually thereafter. Min. Follow up was 7 and mean follow up 9,3 years. Clinical examination included Knee Society Score (KSS), Western Ontario and McMaster Osteoarthritis Index (WOMAC), Oxford Knee Score (OKS), and range of motion (ROM). Competing risk analysis was assessed for survival with respect to indication and failure mode.

KSS, WOMAC, OKS, and ROM significantly improved from the preoperative to the follow up investigations (p < 0.0001). There was no difference in clinical outcome between the primary and the revision group. The overall cumulative incidence for revision for any reason was 23.6% and the cumulative incidence for complications associated with failure of the prothesis was 5.6% at 7 years, respectively. Complications occurred more frequently in the revision group (p = 0.002).

The evaluated RH prosthesis provided reliable and durable results with a minimum follow-up of 7 years. Prosthesis survival was successful considering the complexity of cases. The use of this RH system in primary patients showed high survival rates. Long-term functional and clinical results proved to be satisfying in both revision and primary cases. No adverse events were associated with the new bearing material CFR-PEEK.
EFFECTS OF TRANSPORT AND STORAGE CONDITIONS IN A TROPICAL CLIMATE ON CEMENT SETTING TIMES
Authors: Crombie A. , Boyd J. , Pozzi R.
Published: February 2023

Multiple studies have established an inverse relationship between ambient theatre temperatures and polymethyl methacrylate (PMMA) cement setting times. It is also known that allowing cement to equilibrate to ambient theatre temperatures restores expected setting characteristics. One overlooked entity is the transport and storage conditions of cement. This is important in tropical regions, where extreme temperature and humidity may cause rapid cement setting times, resulting in potentially significant intra-operative complications.

This study investigated the relationship between extreme transport and storage conditions of Antibiotic Simplex cement (Stryker), and the effect on setting times at Cairns Hospital, Far North Queensland, Australia.

Fifty units of cement were divided evenly into a control arm and four experimental arms. The experimental arms were designed to mimic potential transport and storage conditions. They included seven days of storage in a medication fridge, on the hospital loading dock, in a cane shed, and in a Toyota Landcruiser parked outdoors during January 2022. Humidity and temperature readings were recorded.

The samples in each group were evenly distributed to equilibrate to theatre conditions for 1 hour and 24 hours. Setting time was recorded when a no. 15 scalpel blade was unable to mark the surface.

All three ‘hot’ exposures setting times were significantly faster for both 1 hour (ρ=0.001) and 24 hours (ρ=0.024) equilibration times. The difference in setting times for the ‘cold’ exposure was not significant for either equilibration times (ρ=1).

To our knowledge, this is the first study investigating cement setting times in tropical climates. Further studies are required to address the effect of these conditions on biomechanical strength of PMMA cement. We conclude that extreme heat and humidity during transport and storage have a statistically significant effect on cement setting times.
BACTERIOLOGY AND ANTIMICROBIAL SUSCEPTIBILITY OF OSTEOARTICULAR INFECTIONS AT A REGIONAL PAEDIATRIC UNIT IN SOUTH AFRICA
Authors: Horn A. , Cetner C. , Laubscher M. , Tootlah H.
Published: February 2023

Osteoarticular infections (OAI) are a common cause of morbidity in children, and as opposed to adults is usually caused by haematogenous spread. The bacteriology of OAI in children is not well described in the South African context, therefore this study was designed to determine the bacteriology of OAI in our population.

All patients that underwent surgery for the treatment of OAI over a 3-year period were identified and those with positive cultures where organisms were identified from tissue, pus, fluid or blood were included. Duplicate cultures from the same patient were excluded if the organism and antibiotic susceptibility profile was the same. Patients were categorised according to age and class of infection (Septic arthritis, acute osteomyelitis, fracture related infection, post-operative sepsis and chronic osteomyelitis) and organisms were stratified according to these categories.

We identified 132 organisms from 123 samples collected from 86 patients. Most cultured organisms were from children older than 3-years with acute haematogenous septic arthritis, osteomyelitis, or both. Methicillin sensitive Staphylococcus aureus accounted for 56% (74/132) of organisms cultured. There were no cases of MRSA. The Enterobacterales accounted for 17% (22/132) of organisms cultured, mostly in the fracture related and post-operative infection groups. Of these, 6 each were extended spectrum B-lactamase producers and AmpC producers. There were no carbapenemase producing Enterobacterales. Kingella kingae was not isolated in any patient.

Methicillin sensitive S. aureus is the most common infecting organism in paediatric OAI and an anti-staphylococcal penicillin such as cloxacillin or flucloxacillin is the most appropriate empiric treatment for haematogenous OAI in our environment. In fracture related or post-operative infections, Enterobacterales were more frequently cultured, and treatment should be guided by culture and susceptibility results.
PREOPERATIVE ANKLE SWELLING DOES NOT AFFECT POSTOPERATIVE WOUND COMPLICATIONS FOLLOWING ANKLE FRACTURE SURGERY
Authors: Silva A. , Walsh T. , Gray J. , Platt S.
Published: February 2023

Swelling following an ankle fracture is commonly believed to preclude surgical fixation, delaying operative treatment to allow the swelling to subside. This is in an attempt to achieve better soft tissue outcomes. We aim to identify whether pre-operative ankle swelling influences postoperative wound complications following ankle fracture surgery.

This is a prospective cohort study of 80 patients presenting to a tertiary referral centre with operatively managed malleolar ankle fractures.

Ankle swelling was measured visually and then quantitatively using the validated ‘Figure-of-eight’ technique. Follow-up was standardised at 2, 6, and 12 weeks post-operatively. Wound complications, patient co-morbidities, operative time, surgeon experience, and hospital stay duration were recorded.

The complication rate was 8.75% (n=7), with 1 deep infection requiring operative intervention and all others resolving with oral antibiotics and wound cares. There was no significant difference in wound complication rates associated with quantitative ankle swelling (p=0.755), visual assessment of ankle swelling (p=0.647), or time to operative intervention (p=0.270).

Increasing age (p=0.006) and female gender (p=0.049) had a significantly greater probability of wound complications. However, BMI, smoking status, level of the operating surgeon, and tourniquet time were not significantly different.

Visual assessment of ankle swelling had a poor to moderate correlation to ‘Figure-of-eight’ ankle swelling measurements ICC=0.507 (0.325- 0.653).

Neither ankle swelling nor time to surgery correlates with an increased risk of postoperative wound complication in surgically treated malleolar ankle fractures. Increasing patient age and female gender had a significantly greater probability of wound infection, irrespective of swelling. Visual assessment of ankle swelling is unreliable for quantifying true ankle swelling.

Operative intervention at any time after an ankle fracture, irrespective of swelling, is safe and showed no better or worse soft tissue outcomes than those delayed for swelling.
CLINICAL AND RADIOLOGICAL OUTCOMES OF ALL ARTHROSCOPIC MUSCLE ADVANCEMENT FOR MASSIVE RETRACTED POSTEROSUPERIOR CUFF TEARS
Authors: Gupta A. , Jomaa M. , Ker A. , Hollman F. , Singh N. , Maharaj J. , Cutbush K.
Published: February 2023

Massive posterosuperior cuff tears (mRCT) retracted to the glenoid are surgically challenging and often associated with high retear rates. Primary repair is a less-favourable option and other salvage procedures such as SCR and tendon transfers are used. This study presents clinical and radiological outcomes of muscle advancement technique for repair of mRCT.

Sixty-one patients (mean age 57±6, 77% males and 23% females) (66 shoulders) underwent all-arthroscopic rotator cuff repair that included supraspinatus and infraspinatus subperiosteal dissection off scapular bony fossae, lateral advancement of tendon laminae, and tension-free double-layer Lasso Loop repair to footprint.

Pre-and post-operative range of motion (ROM), cuff strength, VAS, Constant, ASES, and UCLA scores were assessed. Radiologic assessment included modified Patte and Goutallier classifications. All patients had MRI at 6 months to evaluate healing and integrity of repair was assessed using Sugaya classification with Sugaya 4 and 5 considered retears.

Advanced fatty degeneration (Goutallier 3-4) was present in 44% and 20% of supraspinatus and infraspinatus. Tendon retraction was to the level of or medial to glenoid in 22%, and just lateral in 66%. 50.8% mRCT extended to teres minor. Subscapularis was partially torn (Lafosse 1-3) in 46% and completely torn (Lafosse 4-5) in 20%.

At mean follow-up (52.4 weeks), a significant increase in ROM, Relative Cuff Strength (from 57% to 90% compared to contralateral side), VAS (from 4 ±2.5 to 1±1.7), Constant (50±17.8 to 74 ±13.0), ASES (52 ±17.5 to 87 ±14.9), and UCLA (16± 4.9 to 30 ±4.9) scores were noted. There were six retears (10%), one failure due to P. acnes infection. 93% returned to pre-injury work and 89% of cases returned to pre-injury sport. Satisfaction rate was 96%.

Muscle advancement technique for mRCT is a viable option with low retear rates, restoration of ROM, strength, and excellent functional outcomes.
OUR EXPERIENCE WITH PEC MAJOR FLAP FOR STERNOCLAVICULAR JOINT INFECTIONS
Authors: Jadav B.
Published: February 2023

Sternoclavicular joint infections are uncommon but severe and complex condition usually in medically complex and compromised hosts. These infections are challenging to treat with risks of infection extending into the mediastinal structures and surgical drainage is often faced with problems of multiple unplanned returns to theatre, chronic non-healing wounds that turn into sinus and the risk of significant clinical escalation and death. Percutaneous aspirations or small incision drainage often provide inadequate drainage and failed control of infection, while open drainage and washout require multidisciplinary support, due to the close proximity of the mediastinal structures and the great vessels as well as failure to heal the wounds and creation of chronic wound or sinus.

We present our series of 8 cases over 6 years where we used the plan of open debridement of the Sternoclavicular joint with medial end of clavicle excision to allow adequate drainage. The surgical incision was not closed primarily, and a suction vacuum dressing was applied until the infection was contained on clinical and laboratory parameters. After the infection was deemed contained, the surgical incision was closed by local muscle flap by transferring the medial upper sternal head of the Pectoralis Major muscle to fill in the sternoclavicular joint defect. This technique provided a consistent and reliable way to overcome the infection and have the wound definitively closed that required no secondary procedures after the flap surgery and no recurrence of infections so far.

We suggest that open and adequate drainage of Sternoclavicular joint staged with vacuum dressing followed by pectoralis major local flap is a reliable technique for achieving control of infection and wound closure for these challenging infections.
A PATIENT / CLIENT SATISFACTION QUESTIONNAIRE FOR AN INDEPENDENT MEDICAL EXAMINATION: A PILOT STUDY
Authors: McPhee I.B.
Published: February 2023

There are numerous patient satisfaction questionnaires by none specific for an Independent Medical Examination (IME). The aim of this study was to develop and evaluate a questionnaire suitable for an IME.

The questionnaire (IMESQ) consisted of five process domains (“Interpersonal manner”, “Communication”, “Technical ability”, “Information exchange”, “Time allocation”) and an outcome domain (“Satisfaction”), each with a five-scale Likert response. An 11-point numerical satisfaction scale (NSS) and a 3-point scale question on the “willing to undergo another examination with the doctor if required” were alternative measures of validation. The questionnaire was tested against numerous independent variables.

Statistical analysis included Spearman correlation ((rS) between the items in the questionnaire and the total score with the NSS, and “willing to undergo another examination with the doctor if required” with point-biserial correlation (rpb). Internal consistent reliability was tested using split-half correlation coefficient (rSB) and Cronbach's alpha coefficient (α). The construct was subjected to Factor Analysis.

The results from 53 respondents were analysed. There was moderate to strong inter-item correlation (rs range 0.57 to 0.83, median 0.67, p < 0.01) and good correlation with the NSS (rs = 0.79, p < 0.01) and dichotomous question (rpb = 0.45, p < 0.01). Five respondents were “neither satisfied or dissatisfied” (Item 6) and 12 recorded “maybe” to further examination. The split-half correlation was strong (rSB= 0.76, p < 0.01). There was good internal consistency reliability (α = 0.92). “Interpersonal manner” (ψ = 4.3) was the only item to have an eigenvalue greater than one, accounting to 72% of the variance across the scale. Eigenvector analysis confirmed the questionnaire was unidimentional.

The IMESQ is a brief questionnaire to assess satisfaction with an IME. It is validated and has good internal consistency reliability. The five process domains can identify areas of suboptimal performance: useful for a 360° audit.
ACCURATE WEAR DETERMINATION IN CLINICAL RADIOGRAPHS AFTER TOTAL KNEE ARTHROPLASTY USING 2D-3D REGISTRATION AND ARTIFICIAL INTELLIGENCE: IN VIVO VALIDATION
Authors: Lutter C. , Grupp T.M. , Mittelmeier W. , Selig M. , Grover P. , Dreischarf M. , Rose G. , Bien T.
Published: February 2023

Polyethylene wear represents a significant risk factor for the long-term success of knee arthroplasty [1]. This work aimed to develop and in vivo validate an automated algorithm for accurate and precise AI based wear measurement in knee arthroplasty using clinical AP radiographs for scientifically meaningful multi-centre studies.

Twenty postoperative radiographs (knee joint AP in standing position) after knee arthroplasty were analysed using the novel algorithm. A convolutional neural network-based segmentation is used to localize the implant components on the X-Ray, and a 2D-3D registration of the CAD implant models precisely calculates the three-dimensional position and orientation of the implants in the joint at the time of acquisition. From this, the minimal distance between the involved implant components is determined, and its postoperative change over time enables the determination of wear in the radiographs.

The measured minimum inlay height of 335 unloaded inlays excluding the weight-induced deformation, served as ground truth for validation and was compared to the algorithmically calculated component distances from 20 radiographs.

With an average weight of 94 kg in the studied TKA patient cohort, it was determined that an average inlay height of 6.160 mm is expected in the patient. Based on the radiographs, the algorithm calculated a minimum component distance of 6.158 mm (SD = 81 µm), which deviated by 2 µm in comparison to the expected inlay height.

An automated method was presented that allows accurate and precise determination of the inlay height and subsequently the wear in knee arthroplasty based on a clinical radiograph and the CAD models. Precision and accuracy are comparable to the current gold standard RSA [2], but without relying on special radiographic setups. The developed method can therefore be used to objectively investigate novel implant materials with meaningful clinical cohorts, thus improving the quality of patient care.
DISTRESS AND CAREER REGRET IN AUSTRALIAN ORTHOPAEDIC SURGICAL TRAINEES: A NATIONAL SURVEY
Authors: Kollias C. , Conyard C. , Formosa M. , Page R. , Incoll I.
Published: February 2023

Physician health is a global concern, with increasing research efforts directed towards the challenge. Australia has limited published specialty-specific well-being data for trainees and consultants in medicine and surgery. We measured distress in Australian Orthopaedic trainees using the Physician Well-Being Index (PWBI, MedEd Web Solutions) using an online anonymous survey sent by the Australian Orthopaedic Association.

The survey response rate was 38% (88/230). Forty-four percent of survey respondents met criteria for distress. Self-reported burnout in the 30 days prior was reported by 63% of respondents. Fifty-eight percent of females and 41% of males met criteria for distress. Of the 19% or respondents identifying as an ethnic minority, 53% were distressed compared to 42% of those identifying as non-ethnic minority. Trainees without a mentor had a 50% distress rate compared to those with a mentor (37% distress rate). Twenty-five percent of all trainees wished they had picked a career outside of medicine and 16% wished they had pursued a medical career other than Orthopaedic Surgery. Of those trainees who had already passed the fellowship exam, 17% wished they had pursued a career outside of medicine and 21% wished they had pursued a medical career in an area other than Orthopaedic Surgery.

These findings suggest concerning rates of career regret and gender-related trends in distress in Australian Orthopaedic trainees. Females may be over-represented in our results as 17% of the source population was female compared to 22% of respondents. Further research is required across all Australian specialties to gain further understanding of factors contributing to distress and to assist in the development of strategy to protect against physician burnout.
HOW DO ANTERIOR CRUCIATE LIGAMENT INJURY AND RECONSTRUCTION AFFECT FUNCTIONAL KNEE EXTENSION? A SYSTEMATIC REVIEW AND META-ANALYSIS
Authors: Erian C. , Erian M. , Ektas N. , Scholes C. , Bell C.
Published: February 2023

Anterior cruciate ligament (ACL) ruptures are debilitating injuries, often managed via ACL reconstruction (ACLR). Reduced range of motion (ROM), particularly loss of extension (LOE), is the most significant contributor to post-operative patient dissatisfaction. LOE may preclude return to sport, increase re-rupture rates and precipitate osteoarthritis.

Passive LOE rates following ACLR have been reported at 15%. However, LOE incidence during active tasks are poorly characterised. Our review sought to determine knee extension angles for active tasks following an ACL injury or ACLR. We hypothesised greater incidences of active LOE following ACL injury or ACLR, compared to uninjured contralateral limbs or controls.

We systematically searched MEDLINE, Embase, Cochrane Library, Scopus, SPORTDiscus, and relevant trials databases for English articles. Included were cohort, cross-sectional, case-controlled or randomised controlled trials analysing adults with ACL injury treated surgically or otherwise, with at least 12-weeks follow-up and reporting either active knee extension angle, active LOE angles or incidence of active knee LOE during functional tasks. The protocol was registered on PROSPERO (CRD42018092295). Subsequent meta-analysis was performed.

After screening, 71 eligible articles were included. Studies were heterogenous in design and quality. Included tasks were overground walking (n=44), running (n=3), hopping/jumping/cutting (n=11) single-leg landing (n=7), and stair climbing (n=6). LOE incidence varied depending on functional activities (33.95-92.74%). LOE incidence did not vary depending on ACL status (67.26% vs. 65.90% vs. 62.57% for ACL intact, ACLD and ACLR, respectively).

We observed no difference in active LOE incidence according to ACL status. Importantly, the observed incidence for active LOE was reliably higher than previously reported rates for passive measures.

Given the discrepancy between active and passive LOE incidence, clinicians may advisably prioritise active ROM during ACL rehabilitation.
PROSTHETIC JOINT INFECTION AFTER HIP HEMIARTHROPLASTY: A DIFFERENT BEAST
Authors: Lewis D.P. , Tarrant S.M. , Dewar D. , Balogh Z.J.
Published: February 2023

Prosthetic joint infections (PJI) are devastating complications. Our knowledge on hip fractureassociated hemiarthroplasty PJI (HHA-PJI) is limited compared to elective arthroplasty. The goal of this study was to describe the epidemiology, risk factors, management, and outcomes for HHA-PJI.

A population-based (465,000) multicentre retrospective analysis of HHAs between 2006-2018 was conducted. PJI was defined by international consensus and treatment success as no return to theatre and survival to 90 days after the initial surgical management of the infection. Univariate, survival and competing risk regression analyses were performed.

1852 HHAs were identified (74% female; age:84±7yrs;90-day-mortality:16.7%). Forty-three (2.3%) patients developed PJI [77±10yrs; 56% female; 90-day-mortality: 20.9%, Hazard-Ratio 1.6 95%CI 1.1-2.3,p=0.023]. The incidence of HHA-PJI was 0.77/100,000/year and 193/100,000/year for HHA. The median time to PJI was 26 (IQR 20-97) days with 53% polymicrobial growth and 41% multi-drug resistant organisms (MDRO). Competing risk regression identified younger age [Sub-Hazard-Ratio(SHR) 0.86, 95%CI 0.8-0.92,p<0.001], chronic kidney disease (SHR 3.41 95%CI 1.36-8.56, p=0.01), body mass index>35 (SHR 6.81, 95%CI 2.25-20.65, p<0.001), urinary tract infection (SHR 1.89, 95%CI 1.02-3.5, p=0.04) and dementia (SHR 9.4, 95%CI 2.89-30.58,p<0.001) as significant risk factors for developing HHA-PJI. When infection treatment was successful (n=15, 38%), median survival was 1632 days (IQR 829-2084), as opposed to 215 days (IQR 20-1245) in those who failed, with a 90-day mortality of 30%(n=12). There was no significant difference in success among debridement, excision arthroplasty or revision arthroplasty.

HHA PJI is uncommon but highly lethal. All currently identified predictors are non-modifiable. Due to the common polymicrobial and MDRO infections our standard antibiotic prophylaxis may not be adequate HHA-PJI is a different disease compared to elective PJI with distinct epidemiology, pathogens, risk factors and outcomes, which require targeted research specific to this unique population.
A COMPARISON OF REVISION RATES FOR STEMMED AND STEMLESS PRIMARY ANATOMIC SHOULDER ARTHROPLASTY WITH ALL-POLYETHYLENE GLENOID COMPONENTS: ANALYSIS FROM THE AUSTRALIAN ORTHOPAEDIC ASSOCIATION NATIONAL JOINT REPLACEMENT REGISTRY
Authors: Gill D.R.J. , Corfield S. , Harries D. , Page R.S.
Published: February 2023

We compared the rate of revision of two classes of primary anatomic shoulder arthroplasty, stemmed (aTSA) and stemless (sTSA) undertaken with cemented all polyethylene glenoid components.

A large national arthroplasty registry identified two cohort groups for comparison, aTSA and sTSA between 1st January 2011 and 31st December 2020. A sub-analysis from 1 January 2017 captured additional patient demographics. The cumulative percentage revision (CPR) was determined using Kaplan-Meier estimates of survivorship and hazard ratios (HR) from Cox proportional hazard models adjusted for age and gender.

Of the 7,533 aTSA procedures, the CPR at 8 years was 5.3% and for 2,567 sTSA procedures was 4.0%. There was no difference in the risk of revision between study groups (p=0.128).

There was an increased risk of revision for aTSA and sTSA undertaken with humeral head sizes <44mm (p=0.006 and p=0.002 respectively). Low mean surgeon volume (MSV) (<10 cases per annum) was a revision risk for aTSA (p=0.033) but not sTSA (p=0.926).

For primary diagnosis osteoarthritis since 2017, low MSV was associated with an increased revision risk for aTSA vs sTSA in the first year (p=0.048). Conversely, low MSV was associated with a decreased revision risk for sTSA in the first 6 months (p<0.001). Predominantly aTSA was revised for loosening (28.8%) and sTSA for instability/dislocation (40.6%).

Revision risk of aTSA and sTSA was associated with humeral head size and mean surgeon volume but not patient characteristics. Inexperienced shoulder arthroplasty surgeons experience lower early revision rates with sTSA in the setting of osteoarthritis. Revision of aTSA and sTSA occurred for differing reasons.
THE ANTERIOR FEMORAL CORTICAL WINDOW AS AN ALTERNATIVE TO EXTENDED TROCHANTERIC OSTEOTOMY IN REVISION HIP SURGERY: EVOLUTION OF SURGICAL TECHNIQUE AND OUTCOMES IN 22 CONSECUTIVE CASES
Authors: Hancock D. , Morley D. , Wyatt M. , Roberts P. , Zhang J. , van Dalen J.
Published: February 2023

When removing femoral cement in revision hip surgery, creating an anterior femoral cortical window is an attractive alternative to extended trochanteric osteotomy. We describe our experience and evolution of this technique, the clinical and radiological results, and functional outcomes.

Between 2006 and 2021 we used this technique in 22 consecutive cases at Whanganui Hospital, New Zealand. The average age at surgery was 74 years (Range 44 to 89 years). 16 cases were for aseptic loosening: six cases for infection.

The technique has evolved to be more precise and since 2019 the combination of CT imaging and 3-D printing technology has allowed patient-specific (PSI) jigs to be created (6 cases). This technique now facilitates cement removal by potentiating exposure through an optimally sized anterior femoral window.

Bone incorporation of the cortical window and functional outcomes were assessed in 22 cases, using computer tomography and Oxford scores respectively at six months post revision surgery. Of the septic cases, five went onto successful stage two procedures, the other to a Girdlestone procedure.

On average, 80% bony incorporation of the cortical window occurred (range 40 −100%). The average Oxford hip score was 37 (range 22 – 48). Functional outcome (Oxford Hip) scores were available in 11 cases (9 pre-PSI jig and 2 using PSI jig). There were two cases with femoral component subsidence (1 using the PSI jig).

This case series has shown the effectiveness of removing a distal femoral cement mantle using an anterior femoral cortical window, now optimized by using a patient specific jig with subsequent reliable bony integration, and functional outcomes comparable with the mean score for revision hip procedures reported in the New Zealand Joint Registry.