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Implant-related infections represent a relatively common and significant challenge in the surgical management of musculoskeletal trauma patients. The third United Kingdom Periprosthetic Joint Infection (UK PJI) Meeting convened in Glasgow on 1 April 2022, and brought together over 180 delegates, representing orthopaedics, infectious diseases, microbiology, plastic surgery, anaesthetics, and allied health professions, including pharmacy and specialist nurses. The meeting comprised a plenary session for all delegates, and separate breakout sessions for fracture-related infection (FRI) and arthroplasty. The UK PJI working group prepared consensus statements in advance of each session, based upon topics that were discussed at previous meetings, and delegates engaged in an anonymous electronic voting process. This article presents the findings of the FRI session, and examines each consensus topic within the context of the contemporary literature., Competing Interests: Declaration of competing interest All authors declare no conflicts of interest with respect to the research, authorship, and publication of this article., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: Bacteriophage (phage) therapy is a promising alternative antimicrobial approach that has the potential to transform the way we treat bacterial infections. The antibiotic resistance crisis is driving renewed interest in phage therapy. There are currently no licensed phage therapy medicinal products and phage therapy is used in small but growing patient numbers on an unlicensed basis., Objectives: This article provides guidelines on the assessment of patient suitability for unlicensed phage therapy for clinicians in the United Kingdom., Sources: This article builds on Health Improvement Scotland's recommendation for the consideration of phage therapy in difficult-to-treat infections and the experience of the author group, who have collectively assessed the suitability of 30 patients for phage therapy., Content: In the United Kingdom, unlicenced medicines, including phages, may be considered to meet special clinical needs. The use of unlicenced medicines is governed by national legislation and local National Health Service trust policies. Phages can be used in any National Health Service trust and decisions about suitability should be made through existing local clinical management pathways. This article sets out guidelines to support local clinical teams in the assessment of patient suitability for phage therapy. Clinical and microbiological considerations are presented, including allergy and pregnancy., Implications: The assessment of patient suitability for phage therapy is within the scope of local clinical teams. Local assessment through existing clinical management pathways will develop confidence and competence in phage therapy among clinical teams nationally and ensure timely patient care., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Aims: The number of revision arthroplasties being performed in the elderly is expected to rise, including revision for infection. The primary aim of this study was to measure the treatment success rate for octogenarians undergoing revision total hip arthroplasty (THA) for periprosthetic joint infection (PJI) compared to a younger cohort. Secondary outcomes were complications and mortality., Methods: Patients undergoing one- or two-stage revision of a primary THA for PJI between January 2008 and January 2021 were identified. Age, sex, BMI, American Society of Anesthesiologists grade, Charlson Comorbidity Index (CCI), McPherson systemic host grade, and causative organism were collated for all patients. PJI was classified as 'confirmed', 'likely', or 'unlikely' according to the 2021 European Bone and Joint Infection Society criteria. Primary outcomes were complications, reoperation, re-revision, and successful treatment of PJI. A total of 37 patients aged 80 years or older and 120 patients aged under 80 years were identified. The octogenarian group had a significantly lower BMI and significantly higher CCI and McPherson systemic host grades compared to the younger cohort., Results: The majority of patients were planned to undergo two-stage revision, although a significantly higher proportion of the octogenarians did not proceed with the second stage (38.7% (n = 12) vs 14.8% (n = 16); p = 0.003). Although there was some evidence of a lower complication rate in the younger cohort, this did not reach statistical significance (p = 0.065). No significant difference in reoperation (21.6% (n = 8) vs 25.0% (n = 30); p = 0.675) or re-revision rate (8.1% (n = 3) vs 16.7% (n = 20); p = 0.288) was identified between the groups. There was no difference in treatment success between groups (octogenarian 89.2% (n = 33) vs control 82.5% (n = 99); p = 0.444)., Conclusion: When compared to a younger cohort, octogenarians did not show a significant difference in complication, re-revision, or treatment success rates. However, given they are less likely to be eligible to proceed with second stage revision, consideration should be given to either single-stage revision or use of an articulated spacer to maximize functional outcomes., Competing Interests: None declared., (© 2024 The British Editorial Society of Bone & Joint Surgery.)

Aims: Femoral periprosthetic fractures are rising in incidence. Their management is complex and carries a high associated mortality. Unlike native hip fractures, there are no guidelines advising on time to theatre in this group. We aim to determine whether delaying surgical intervention influences morbidity or mortality in femoral periprosthetic fractures., Methods: We identified all periprosthetic fractures around a hip or knee arthroplasty from our prospectively collated database between 2012 and 2021. Patients were categorized into early or delayed intervention based on time from admission to surgery (early = ≤ 36 hours, delayed > 36 hours). Patient demographics, existing implants, Unified Classification System fracture subtype, acute medical issues on admission, preoperative haemoglobin, blood transfusion requirement, and length of hospital stay were identified for all patients. Complication and mortality rates were compared between groups., Results: A total of 365 patients were identified: 140 in the early and 225 in the delayed intervention group. Mortality rate was 4.1% at 30 days and 19.2% at one year. There was some indication that those who had surgery within 36 hours had a higher mortality rate, but this did not reach statistical significance at 30 days (p = 0.078) or one year (p = 0.051). Univariate analysis demonstrated that age, preoperative haemoglobin, acute medical issue on admission, and the presence of postoperative complications influenced 30-day and one-year mortality. Using a multivariate model, age and preoperative haemoglobin were independently predictive factors for one-year mortality (odds ratio (OR) 1.071; p < 0.001 and OR 0.980; p = 0.020). There was no association between timing of surgery and postoperative complications. Postoperative complications were more likely with increasing age (OR 1.032; p = 0.001) and revision arthroplasty compared to internal fixation (OR 0.481; p = 0.001)., Conclusion: While early intervention may be preferable to reduce prolonged immobilization, there is no evidence that delaying surgery beyond 36 hours increases mortality or complications in patients with a femoral periprosthetic fracture., Competing Interests: R. M. D. Meek declares payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from DePuy, Stryker, and Palacademy; and being the hip specialty editor for The Bone & Joint Journal, all of which is unrelated to this article., (© 2024 Kennedy et al.)

Considerable variation in practice exists in the prevention, diagnosis, and treatment of periprosthetic joint infection (PJI), which is a devastating complication for patients and surgeons. The consensus principle has been increasingly embraced by the orthopaedic community to help guide practice, especially where high-level evidence remains unavailable. The third United Kingdom Periprosthetic Joint Infection (UK PJI) Meeting was held in Glasgow on April 1, 2022, with more than 180 delegates in attendance, representing orthopaedics, microbiology, infectious diseases, plastic surgery, anesthetics, and allied health professions, including pharmacy and arthroplasty nurses. The meeting comprised a combined session for all delegates, and separate breakout sessions for arthroplasty and fracture-related infection. Consensus questions for each session were prepared in advance by the UK PJI working group, based upon topics that were proposed at previous UK PJI Meetings, and delegates participated in an anonymized electronic voting process. We present the findings of the combined and arthroplasty sessions of the meeting in this article, and each consensus topic is discussed in relation to the contemporary literature., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objectives: Little research exists on how risk scores are used in counselling. We examined (a) how Breast Cancer Risk Assessment Tool (BCRAT) scores are presented during counselling; (b) how women react and (c) discuss them afterwards., Design: Consultations were video-recorded and participants were interviewed after the consultation as part of the NRG Oncology/National Surgical Adjuvant Breast and Bowel Project Decision-Making Project 1 (NSABP DMP-1)., Setting: Two NSABP DMP-1 breast cancer care centres in the USA: one large comprehensive cancer centre serving a high-risk population and an academic safety-net medical centre in an urban setting., Participants: Thirty women evaluated for breast cancer risk and their counselling providers were included., Methods: Participants who were identified as at increased risk of breast cancer were recruited to participate in qualitative study with a video-recorded consultation and subsequent semi-structured interview that included giving feedback and input after viewing their own consultation. Consultation videos were summarised jointly and inductively as a team.tThe interview material was searched deductively for text segments that contained the inductively derived themes related to risk assessment. Subgroup analysis according to demographic variables such as age and Gail score were conducted, investigating reactions to risk scores and contrasting and comparing them with the pertinent video analysis data. From this, four descriptive categories of reactions to risk scores emerged. The descriptive categories were clearly defined after 19 interviews; all 30 interviews fit principally into one of the four descriptive categories., Results: Risk scores were individualised and given meaning by providers through: (a) presenting thresholds, (b) making comparisons and (c) emphasising or minimising the calculated risk. The risk score information elicited little reaction from participants during consultations, though some added to, agreed with or qualified the provider's information. During interviews, participants reacted to the numbers in four primary ways: (a) engaging easily with numbers; (b) expressing greater anxiety after discussing the risk score; (c) accepting the risk score and (d) not talking about the risk score., Conclusions: Our study highlights the necessity that patients' experiences must be understood and put into relation to risk assessment information to become a meaningful treatment decision-making tool, for instance by categorising patients' information engagement into types., Trial Registration Number: NCT01399359., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: There is increasing evidence that both low surgeon and centre case volumes are associated with poorer outcomes following Revision Knee Arthroplasty (rTKA). Given the unique challenges faced in Scotland relating to funding and geography, understanding details on the complexity of cases is required to guide development of future rTKA services., Methods: Utilising the Scottish Collaborative Orthopaedic Trainee Research Network (SCOTnet) a retrospective review of all Scottish 2019 rTKA cases was undertaken. Regional leads co-ordinated local data collection using individual case note review. The number of cases performed by regions, hospitals and individual surgeons were identified. Patient demographics and case complexity (Revision Knee Complexity Classification [RKCC]) were also collected. Results were compared against current standards., Results: 17 units performed rTKA, delivered by 77 surgeons. A total of 506 cases were included. The mean age was 69 years (46% male). Revision for infection accounted for 147/506 (29%) cases. Extensor compromise was present in 35/506 (7%) and 11/506 (2%) required soft tissue reconstruction. According to the RKCC - 214/503 (43%) were classified as R1 (Less complex cases), 228/503 (45%) R2 (complex cases), and 61/503 (12%) R3 (most complex / salvage cases). 5/17 (29%) units met current national guidelines for case volume/year, with only 11/77 (14%) surgeons meeting recommended individual case volumes. 37/77 (48%) surgeons performed ≤ 2 cases per year., Conclusions: Most individual centre volumes could be increased by re-organising services or locations providing rTKA within a region. This should provide better access to Multidisciplinary Team (MDT) involvement. We recorded a significant number of very low volume surgeons (≤2 year) that is contradictory to current evidence-based practice., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.)

Aims: The aim of this study was to assess the clinical and radiological outcomes of an antiprotrusio acetabular cage (APC) when used in the surgical treatment of periacetabular bone metastases., Methods: This retrospective cohort study using a prospectively collected database involved 56 patients who underwent acetabular reconstruction for periacetabular bone metastases or haematological malignancy using a single APC between January 2009 and 2020. The mean follow-up was 20 months (1 to 143). The primary outcome measure was implant survival. Postoperative radiographs were analyzed for loosening and failure. Patient and implant survival were assessed using a competing risk analysis. Secondary parameters included primary malignancy, oncological treatment, surgical factors, length of stay in hospital, and postoperative complications., Results: A total of 33 patients (59%) died during the study period at a mean of 15 months postoperatively (1 to 63). No patient had radiological evidence of loosening or failure. Acetabular component survival was 100%. Three patients (5.4%) had further surgery; one (1.8%) underwent revision of the femoral component for dislocation, one required debridement with implant retention for periprosthetic joint infection, and one required closed reduction for dislocation. Using death as a competing risk, at 100 months, the probability of revision was 0.036 and the risk of death was 0.84., Conclusion: With appropriate patient selection, the antiprotrusio cage offers good implant survival, with a reasonable perioperative complication rate in this high-risk group of patients when managing metastatic disease or haematological malignancy around the acetabulum. Cite this article: Bone Joint J  2022;104-B(4):504-509.

Background: To compare outcomes of revision to a long uncemented stem with cement-in-cement revision for Vancouver B2 periprosthetic fracture (PPF)., Methods: Patients undergoing surgery for a Vancouver B2 PPF in a cemented stem from 2008 to 2018 were identified using our prospectively collated database., Results: We identified 43 uncemented and 29 cement-in-cement revisions. Cement-in-cement revision had a shorter operative time, reduction in certain complications, no increased rate of non-union, lower degree of stem subsidence and no difference in re-revision rate., Conclusion: With appropriate patient selection, both cement-in-cement and long uncemented stem revision represent appropriate treatment options for Vancouver B2 fractures., Competing Interests: None., (© 2022 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. All rights reserved.)

Models of bone remodelling could be useful in drug discovery, particularly if the model is one that replicates bone regeneration with reduction in osteoclast activity. Here we use nanovibrational stimulation to achieve this in a 3D co-culture of primary human osteoprogenitor and osteoclast progenitor cells. We show that 1000 Hz frequency, 40 nm amplitude vibration reduces osteoclast formation and activity in human mononuclear CD14 + blood cells. Additionally, this nanoscale vibration both enhances osteogenesis and reduces osteoclastogenesis in a co-culture of primary human bone marrow stromal cells and bone marrow hematopoietic cells. Further, we use metabolomics to identify Akt (protein kinase C) as a potential mediator. Akt is known to be involved in bone differentiation via transforming growth factor beta 1 (TGFβ1) and bone morphogenetic protein 2 (BMP2) and it has been implicated in reduced osteoclast activity via Guanine nucleotide-binding protein subunit α13 (Gα13). With further validation, our nanovibrational bioreactor could be used to help provide humanised 3D models for drug screening., (© 2021. The Author(s).)

Aims: Cement-in-cement revision of the femoral component represents a widely practised technique for a variety of indications in revision total hip arthroplasty. In this study, we compare the clinical and radiological outcomes of two polished tapered femoral components., Methods: From our prospectively collated database, we identified all patients undergoing cement-in-cement revision from January 2005 to January 2013 who had a minimum of two years' follow-up. All cases were performed by the senior author using either an Exeter short revision stem or the C-Stem AMT high offset No. 1 prosthesis. Patients were followed-up annually with clinical and radiological assessment., Results: A total of 97 patients matched the inclusion criteria (50 Exeter and 47 C-Stem AMT components). There were no significant differences between the patient demographic data in either group. Mean follow-up was 9.7 years. A significant improvement in Oxford Hip Score (OHS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and 12-item Short-Form Survey (SF-12) scores was observed in both cohorts. Leg lengths were significantly shorter in the Exeter group, with a mean of -4 mm in this cohort compared with 0 mm in the C-Stem AMT group. One patient in the Exeter group had early evidence of radiological loosening. In total, 16 patients (15%) underwent further revision of the femoral component (seven in the C-Stem AMT group and nine in the Exeter group). No femoral components were revised for aseptic loosening. There were two cases of femoral component fracture in the Exeter group., Conclusion: Our series shows promising mid-term outcomes for the cement-in-cement revision technique using either the Exeter or C-Stem AMT components. These results demonstrate that cement-in-cement revision using a double or triple taper-slip design is a safe and reliable technique when used for the correct indications. Cite this article: Bone Joint J  2021;103-B(7):1215-1221.

Aims: Periprosthetic hip and knee infection remains one of the most severe complications following arthroplasty, with an incidence between 0.5% to 1%. This study compares the outcomes of revision surgery for periprosthetic joint infection (PJI) following hip and knee arthroplasty prior to and after implementation of a specialist PJI multidisciplinary team (MDT)., Methods: Data was retrospectively analyzed from a single centre. In all, 29 consecutive joints prior to the implementation of an infection MDT in November 2016 were compared with 29 consecutive joints subsequent to the MDT conception. All individuals who underwent a debridement antibiotics and implant retention (DAIR) procedure, a one-stage revision, or a two-stage revision for an acute or chronic PJI in this time period were included. The definition of successfully treated PJI was based on the Delphi international multidisciplinary consensus., Results: There were no statistically significant differences in patient demographics or comorbidities between the groups. There was also no significant difference in length of overall hospital stay (p = 0.530). The time taken for formal microbiology advice was significantly shorter in the post MDT group (p = 0.0001). There was a significant difference in failure rates between the two groups (p = 0.001), with 12 individuals (41.38%) pre-MDT requiring further revision surgery compared with one individual (6.67%) post-MDT inception., Conclusion: Our standardized multidisciplinary approach for periprosthetic knee and hip joint infection shows a significant reduction in failure rates following revision surgery. Following implementation of our MDT, our success rate in treating PJI is 96.55%, higher than what current literature suggests. We advocate the role of a specialist infection MDT in the management of patients with a PJI to allow an individualized patient-centred approach and care plan, thereby reducing postoperative complications and failure rates. Cite this article: Bone Jt Open  2021;2(7):509-514.

The research objective was to rapidly scale up and spread a proven learning collaborative approach (intervention) for adult vaccination rates for influenza and pneumococcal disease from 7 to 39 US health care organizations and to examine improvement in adult immunization rates after scale-up. Comparative analyses were conducted between intervention and nonintervention propensity score-matched providers on vaccination rates using a difference-in-differences approach. Qualitative data, collected during site visits and in-person and virtual meetings, were used to enhance understanding of quantitative results. In 2017-2018, an analysis of a subset of sites (n = 9) from 2 intervention cohorts (∼20 sites each) demonstrated greater improvement than their matched providers in pneumococcal vaccinations (PV) for patients ages ≥65 years (treatment effect range: 1.4%-3.7%, P  < 0.01) and PV for high-risk patients (eg, with immunocompromising conditions) aged 19-64 years (0.8%-1.6%, P  < 0.01). Significant effects were observed in one of the study cohorts for PV for at-risk patients (eg, with diabetes) aged 19-64 years (1.7%, P  < 0.01), and influenza vaccination rates (2.4%, P  < 0.001). Individual health systems demonstrated even greater improvements across all 4 vaccinations: 9.5% influenza; 8.7% PV ages ≥65 years; 11.8% PV high-risk; 16.3% PV at-risk (all P  < 0.01 ). Results demonstrated that a 7-site pilot could be successfully scaled to 39 additional sites, with similar improvements in vaccination rates. Between 2014 and 2018, vaccination improvements among all 46 groups (7 pilot, 39 in subsequent cohorts) resulted in an estimated 5.5 million adult vaccinations administered or documented in 27 states.

Purpose: This study evaluated pain control after wrist operations using a long-acting local anesthetic, liposomal bupivacaine, compared with the standard local anesthetic, bupivacaine HCl., Methods: Patients undergoing elective carpometacarpal joint arthroplasty and proximal row carpectomy were eligible. Those meeting inclusion criteria were enrolled before surgery and were randomized to receive an intraoperative injection of liposomal bupivacaine or bupivacaine HCl. Primary outcomes included intraoperative and postoperative opioid requirements and pain levels. On the first 4 postoperative days, phone contact assessed pain level by numeric rating scale, number of opioids taken in each 24-hour period, and efficacy of anesthesia and opioid side effects with overall benefit of analgesia score., Results: Postoperative pain scores for 52 patients measured by numeric rating scale demonstrated that liposomal bupivacaine and bupivacaine HCl were similar for pain control. Pain scores and opioid use were similar during the first 4 postoperative days. Opioid use on day 1 was slightly lower with liposomal bupivacaine. There were no statistically significant differences in any postoperative outcome between groups., Conclusions: Liposomal bupivacaine and bupivacaine HCl have similar effects in the treatment of early postoperative pain after trapeziometacarpal suspension arthroplasty and proximal row carpectomy. Neither drug demonstrated a clear advantage in this study., Type of Study/level of Evidence: Therapeutic II., (Copyright © 2020 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

The objective of this research was to test the impact of a learning collaborative model (intervention) on adult vaccination rates for influenza and pneumococcal disease. A mixed methods approach was used to identify changes in adult vaccination rates over time and organizational factors contributing to successful programs. Provider-level propensity scores were used to match intervention to non-intervention providers to control for inherent selection bias of participating organizations. Comparative analyses were conducted between intervention and non-intervention sites on vaccination rates, using a difference-in-differences approach. Qualitative data (eg, semi-structured interviews) were analyzed using a constant comparison approach to identify themes related to successful strategies. From 2014-2016, intervention providers demonstrated greater improvement than their matched providers in pneumococcal vaccinations (PV) for patients aged 65 years and older (treatment effect: 4.3%, P  < 0.05) and PV for high-risk patients (eg, with immunocompromising conditions) aged 19-64 years (2.7%, P  < 0.001). Significant effects were also observed for PV for at-risk patients (eg, with diabetes) aged 19-64 years (1.7%, P  < 0.05). Individual health systems demonstrated even greater improvements (eg, greater increase in PV rates for patients aged 65 years and older), with treatment effects as high as 20.4% ( P  < 0.05). A learning collaborative approach was demonstrated to be an effective approach to improve adult vaccination rates among participating integrated delivery systems and medical groups. Factors associated with success included organization type (ie, integrated delivery systems) and systems characterized by a positive learning climate and collaborative culture.

The Universal 2 total wrist arthroplasty is intended to alleviate wrist pain and restore function. There is limited evidence regarding its success and safety. We report outcomes in 48 wrists of 46 patients with Universal 2 arthroplasty between 2006 and 2014. We recorded range of motion of the operated wrist, patient satisfaction, complication and revision rates, and radiological appearances of the wrists with mean follow-up of 7 years (3.5 to 11 years). We found a significant improvement in DASH scores after surgery, with active range of wrist motion being 33° flexion and 24° extension. Thirty-nine patients would undergo the procedure again if he had similar wrist problems. Twenty-three patients had loosening of at least one component of the implant. Complications were found in 13 wrists; seven underwent revision. We conclude that the Universal 2 arthroplasty produces significant improvements in DASH scores and high levels of satisfaction of the patients. However, the surgery has a high complication rate., Level of Evidence: IV.

Objective: Resident clinics (RCs) are intended to catalyze the achievement of educational milestones through progressively autonomous patient care. However, few studies quantify their effect on competency-based surgical education, and no previous publications focus on hand surgery RCs (HRCs). We demonstrate the achievement of progressive surgical autonomy in an HRC model., Design: A retrospective review of all patients seen in a weekly half-day HRC from October 2010 to October 2015 was conducted. Investigators compiled data on patient demographics, provider encounters, operational statistics, operative details, and dictated surgical autonomy on an ascending 5 point scoring system., Setting: A tertiary hand surgery referral center., Results: A total of 2295 HRC patients were evaluated during the study period in 5173 clinic visits. There was an average of 22.6 patients per clinic, including 9.0 new patients with 6.5 emergency room referrals. Totally, 825 operations were performed by 39 residents. Trainee autonomy averaged 2.1/5 (standard deviation [SD] = 1.2), 3.4/5 (SD = 1.3), 2.1/5 (SD = 1.3), 3.4/5 (SD = 1.2), 3.2/5 (SD = 1.5), 3.5/5 (SD = 1.5), 4.0/5 (SD = 1.2), 4.1/5 (SD = 1.2), in postgraduate years 1 to 8, respectively. Linear mixed model analysis demonstrated training level significantly effected operative autonomy (p = 0.0001). Continuity of care was maintained in 79.3% of cases, and patients were followed an average of 3.9 clinic encounters over 12.4 weeks., Conclusions: Our HRC appears to enable surgical trainees to practice supervised autonomous surgical care and provide a forum in which to observe progressive operative competency achievement during hand surgery training. Future studies comparing HRC models to non-RC models will be required to further define quality-of-care delivery within RCs., (Copyright © 2017. Published by Elsevier Inc.)

We examined differences in complication rates between obese and non-obese patients undergoing revision total hip arthroplasty. Sixty-five patients with a BMI ≥30 kg/m 2 and 54 patients with a BMI of <30 kg/m 2 were identified. Obese patients were 2.5 times more likely to suffer a complication than non-obese (38.4% cf 14.8%, p = 0.02). Obese patients were more likely to experience dislocation, leg length discrepancy, fracture, implant loosening, infection and pulmonary embolus. The obese group had a significantly higher revision rate (12.3% cf 1.8%, p = 0.039). Obese patients should be counselled pre-operatively on their elevated risk.

Background and Aims Developmental dysplasia of the hip is a common cause of osteoarthritis. Periacetabular osteotomy can restore femoral head coverage; however, it is reserved for patients with minimal articular degeneration. We examined the relationship between delays in diagnosis and outcomes. Methods We identified patients presenting to a hip specialist with a new diagnosis of hip dysplasia. The time taken between patients presenting to their general practitioner and attending the young adult hip clinic was established. Patients were stratified into Early, Moderate and Late Referral groups. Hip and SF-12 questionnaires were completed. Radiographs were graded according to the Tönnis classification system and the outcome following hip specialist review documented. Results Fifty-one patients were identified. Mean time from attending a general practitioner to review at the young adult hip clinic was 40.4 months. Lower hip and SF-12 scores, and higher radiological osteoarthritis grades were found in the Moderate and Late Referral groups. A higher proportion of the Moderate and Late Referral group underwent total hip arthroplasty rather than periacetabular osteotomy. Conclusion Delays in referring a patient to a hip specialist are associated with poorer outcomes. We propose pelvic radiographs are requested early by general practitioners to allow prompt diagnosis and referral to a hip specialist.

Background: Resident clinics are thought to catalyze educational milestone achievement through opportunities for progressively autonomous surgical care, but studies are lacking for general plastic surgery resident clinics (PSRCs). We demonstrate the achievement of increased surgical autonomy and continuity of care in a PSRC., Methods: A retrospective review of all patients seen in a PSRC from October 1, 2010, to October 1, 2015, was conducted. Our PSRC is supervised by faculty plastic surgery attendings, though primarily run by chief residents in an accredited independent plastic surgery training program. Surgical autonomy was scored on a 5-point scale based on dictated operative reports. Graduated chief residents were additionally surveyed by anonymous online survey., Results: Thousand one hundred forty-four patients were seen in 3,390 clinic visits. Six hundred fifty-three operations were performed by 23 total residents, including 10 graduating chiefs. Senior resident autonomy averaged 3.5/5 (SD = 1.5), 3.6/5 (SD = 1.5), to 3.8/5 (SD = 1.3) in postgraduate years 6, 7, and 8, respectively. A linear mixed model analysis demonstrated that training level had a significant impact on operative autonomy when comparing postgraduate years 6 and 8 ( P = 0.026). Graduated residents' survey responses (N = 10; 100% response rate) regarded PSRC as valuable for surgical experience (4.1/5), operative autonomy (4.4/5), medical knowledge development (4.7/5), and the practice of Accreditation Council of Graduate Medical Education core competencies (4.3/5). Preoperative or postoperative continuity of care was maintained in 93.5% of cases., Conclusion: The achievement of progressive surgical autonomy may be demonstrated within a PSRC model.

Background: Ceramic-on-ceramic total hip arthroplasties (THA) are commonly implanted. We investigated the incidence of noise in ceramic-on-ceramic and determined any association with patient satisfaction and hip scores., Methods: We recruited 140 THA. Questionnaires were completed to assess the incidence and frequency of noise, and satisfaction level. Hip and SF-12 scores were recorded., Results: Forty-two patients (30%) were aware of noise production. Patients with noise production had lower satisfaction, mean hip and SF-12 scores than those with silent hips., Conclusion: Given the high incidence of noise in ceramic-on-ceramic THA, patients should be counselled on this risk pre-operatively.

The prognosis of systemic lupus erythematosus (SLE) has greatly improved in recent years, resulting in an increased number of patients reporting musculoskeletal complications such as osteonecrosis of the femoral head. Total hip arthroplasty (THA) can be utilised to alleviate the pain associated with this; however postoperative outcomes in patients with SLE are uncertain. A systematic review of the literature was conducted to identify articles presenting results of THA in SLE, and nine suitable papers were found. All papers were level IV evidence. Pooling the results, a total of 162 patients underwent 214 total hip arthroplasties. Mean follow-up was 72.5 months. The mean Harris Hip Score improved from 45.5 preoperatively to 88.6 and last follow-up. Seventeen percent of patients experienced at least one complication. Superficial wound infection occurred in 3.3%. Revision was required in 2.8% of cases. The mortality rate was 18.5% however no deaths were attributable to undergoing THA. Given the paucity of data present in the literature, more studies are required to adequately assess the postoperative outcomes of THA in patients with SLE, particularly complication rates.

Background: Growth arrest lines can develop within the skeleton after physiological stress or trauma. They are usually evident on radiographs as transverse lines in the metaphyses and have been used in fields from palaeontology to orthopaedics. This report consists of three cases, two of which describe growth arrest lines in an intra-epiphyseal site hitherto rarely documented, and a third demonstrating their clinical application., Case Presentation: Case 1 describes a 9-year-old who suffered a knee hyperflexion injury requiring anterior cruciate ligament and posterior cruciate ligament reattachments. She subsequently developed a marked distal femoral intra-epiphyseal arrest silhouette, as well as metaphyseal arrest lines in the femur, tibia and fibula. Case 2 describes an 8-year-old who sustained a tibial spine fracture and underwent open reduction and internal fixation. Subsequent imaging shows a further example of femoral intra-epiphyseal arrest silhouette as well as tibia and fibula metaphyseal arrest lines. Case 3 describes a 10-year-old who sustained a distal tibia fracture which was managed with open reduction and internal fixation. Subsequently the metaphyseal growth arrest line was parallel to the physis, suggesting no growth arrest (a danger with such a fracture)., Conclusion: This case series describes two examples of rarely described intra-epiphyseal growth arrest silhouettes and demonstrates the usefulness of arrest lines when assessing for growth plate damage.

Background: The outcomes of total hip arthroplasty (THA) in the elderly population are uncertain. With the rapid expansion of this population group, this study aims to determine whether increasing age affects the outcomes of THA by utilising the largest patient cohort and follow-up period within the literature., Patients and Methods: All patients of 80 years and over who underwent primary THA between 1994 and 2004 at the authors' institution were compared to a cohort aged under 80 with the same diagnoses and during the same time period. Mean follow-up time was 5.9 years with a select group being reviewed at year 10., Results: Pain scores were comparable at year five, whilst mean Harris hip scores were significantly lower in the octogenarians. Median hospital stay was three days longer in the elderly group. Complication rates were also higher (38.1% cf 28.7%) however fewer cases of revision were noted (1.4% cf 3.8%). Patient satisfaction was comparable between groups., Conclusion: This study suggests pain improvement, low revision rates and high satisfaction are sufficient to justify THA in the elderly population., (Copyright © 2013 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.)

Background: TKA is one of the most commonly performed procedures in the elderly, yet whether age influences postoperative pain, function, and complication rates is not fully understood for this group. This is because the current literature has limited followup, small sample sizes, and no comparator group., Questions/purposes: We therefore asked if increasing age adversely affects postoperative pain, Knee Society Scores(©), and complication rates., Methods: We retrospectively reviewed all 438 patients 80 years or older who underwent primary TKA between 1995 and 2005. We established a comparator group of 2754 patients younger than 80 years. We assessed pain, the Knee Society Score(©) (KSS), and the Knee Society Function Score(©) (KSFS). The number and type of complications were recorded and those graded 2 or more using the classification of Dindo et al. were analyzed. Minimum followup was 5 years (mean, 6 years; range, 5-15.5 years)., Results: We found no difference in pain scores at 3, 5, and 10 years between the two groups. The KSS was comparable between groups at Year 5, but the KSFS was lower in the octogenarians. Major complications rates were higher in the octogenarian group (19% versus 15%)., Conclusions: When compared with younger patients, octogenarians can expect comparable pain relief and KSS but lower function and more complications.

Object: The aim of this study was to determine the preoperative predictors of the extent of resection and endocrinological remission following endonasal endoscopic removal of growth hormone (GH)-secreting pituitary adenomas., Methods: The authors analyzed a prospectively collected database of 24 consecutive acromegalic patients who underwent endoscopic endonasal transsphenoidal surgery. The extent of resection was evaluated on postoperative contrast-enhanced MR imaging. Endocrinological remission was defined as normal insulin-like growth factor I (IGFI) serum levels and either a nadir GH level of < 0.4 ng/ml after an oral glucose load or a basal GH serum level < 1 ng/ml., Results: The majority of acromegalic patients (83%) had macroadenomas > 1 cm in maximum diameter. Gross-total resection was achieved in 17 (71%) of 24 patients. Notably, endoscopic transsphenoidal surgery allowed complete resection of all lesions without cavernous sinus invasion, regardless of the suprasellar extent. Biochemical remission was achieved in 11 (46%) of 24 patients. A smaller tumor volume and a postoperative reduction in GH serum levels were associated with a higher rate of biochemical cure (p < 0.05). During a 23-month follow-up period 5 patients (21%) underwent Gamma Knife treatment of any residual disease to further reduce excess GH production. Twenty patients (83%) reported significant relief of their symptoms, while 3 (13%) considered their symptoms stable. Two patients (8%) with large macroadenomas experienced postoperative panhypopituitarism, and 2 patients (8%) suffered from CSF leaks, which were treated with lumbar CSF diversion., Conclusions: A purely endoscopic endonasal transsphenoidal adenoma resection leads to a high rate of gross-total tumor resection and endocrinological remission in acromegalic patients, even those harboring macroadenomas with wide suprasellar extension. Extended approaches and angled endoscopes are useful tools for increasing the extent of resection.

Gardner's syndrome (GS) is a hereditary autosomal dominant disease of the colon that presents with extra-colonic manifestations such as osteomas, skin lesions and dental abnormalities. Osteomas are commonly found in the skull, jaws and the paranasal sinuses. We present a family of four sisters affected with GS with a wide range of anomalies. The role of Cone beam computed tomography (CBCT) in the early detection and evaluation of osteomas and dental anomalies with precise assessment of their relationship to adjacent anatomic structures is described here in detail. The careful interpretation of CBCT may be of a great value in surgical and orthodontic treatment planning in the presence of jaw lesions. Management of dental problems in GS may be challenging due to the presence of odontomas and increased bone density. A multidisciplinary approach in the management of GS can achieve the best treatment results.

A general and efficient route to 2-substituted 1,3-cyclopentadiones 3 has been developed. This operationally simple, two-step procedure is amenable to multigram scale preparations of these useful synthetic intermediates. These compounds are then transformed to previously unknown, higher analogues of the Hajos-Parrish-Eder-Sauer-Wiechert ketone (enone 1, R = Me) following an enantioselective Robinson annulation.

Basal cell carcinoma is exceedingly common, but tumors >5 cm in size or giant basal cell carcinomas (GBCCs) are rare. We retrospectively review 10 GBCCs in 8 patients treated by aggressive surgical excision and reconstruction in a single operative procedure. With the exception of 1 chest lesion, all GBCCs involved the face or scalp. The 10 large defects were reconstructed with 5 free-tissue transfers, 2 pedicled musculocutaneous flaps, and 3 rotational skin flaps. There has been no evidence of local recurrence or metastasis in a mean follow-up of 29 months. Neglect has a well-established role in the presence of GBCCs, with undiagnosed preexisting medical problems also common. Surgical excision and reconstruction is the treatment of choice and can be readily accomplished in a single procedure with few complications, good oncologic control, and acceptable cosmetic results.

A concise, efficient and modular approach to the tylophora alkaloids is described, a family of potent cytotoxic agents that are equally effective against drug sensitive and multidrug resistant cancer cell lines. The advantages of the chosen route are illustrated by the total syntheses of the phenanthroquinolizidine cryptopleurine (1) and the phenanthroindolizidines (-)-antofine (2), (-)-tylophorine (3), and their only recently isolated congener (-)-ficuseptine C (4). The key steps consist in a Suzuki cross-coupling between a (commercial) boronic acid and a simple aryl-1,2-dihalide followed by elaboration of the resulting products into the corresponding 2-alkynyl-biphenyl derivatives 27, 33, 41 and 46. The latter undergo PtCl2-catalyzed cycloisomerizations with formation of the functionalized phenanthrenes 28, 34, 42 and 47, which were transformed into the targeted alkaloids by a deprotection/Pictet-Spengler annulation tandem. Due to the flexibility and robust character of this approach, it might enable a systematic exploration of the pharmacological profile of this promising class of bioactive natural products.

We report a unusual presentation of B-cell lymphoma in the chronically inflamed synovium of a 64-year-old man with an 18-year history of rheumatoid arthritis that was treated with methotrexate.

Iron oxide nanoparticles have been shown to magnetically label cells in order to visualize them in vivo via MR imaging. This technology has yet to be implemented in insulin secreting cells, thus it is not known whether the presence of these nanoparticles in the cytoplasm of the cells affects insulin secretion. This study investigates the effectiveness and consequence of labeling mouse insulinoma betaTC3 and betaTC-tet cells with monocrystalline iron oxide nanoparticles (MION). Our data show that MION can be internalized in both betaTC3 and betaTC-tet cells following a 24h exposure to 0.02mg/ml MION solution. The metabolic and secretory activities of both MION-labeled cell lines were statistically indistinguishable from sham treatment. Furthermore, cell viability and apoptosis remained constant throughout the cell's exposure to MION. Finally, MR images demonstrated significant contrast between labeled and sham-treated cells. Thus, labeling murine insulinoma cell lines with magnetic iron oxide nanoparticles does not hinder their insulin secretion, while it provides MR imaging contrast.

A full account of the development of the first catalytic manifold for the additions of allylboronates to aldehydes is described. The thermal additions (both diastereospecific and enantioselective) of 2-carboxyester 3,3-disubstituted allylboronates 1 to both aromatic and aliphatic aldehydes give biologically and synthetically important exo-methylene butyrolactones 2 containing a beta-quaternary carbon center. Although the thermal reaction requires 14 d at room temperature to reach completion, the presence of certain metal salts allows for a 12-16 h reaction while preserving the diastereospecificity observed in the uncatalyzed process. Preliminary mechanistic studies on the origin of the catalytic effect are described as well as stereoselective transformations of lactones 2 into cyclic and acyclic stereotriads with potential usefulness as synthetic intermediates.

Despite the popularity of boron and silicon allylation reagents in stereocontrolled synthesis, they suffer from a number of inherent limitations that have slowed down their development as synthetic tools for nucleophilic additions to carbonyl compounds and imine derivatives. These limitations are the low reactivity and diastereoselectivity of allyl trialkylsilane reagents, and the lack of catalytic systems for the activation and substoichiometric control of enantioselectivity in the additions of allyl boron reagents. To develop more efficient and general methods for the control of absolute stereochemistry in the resulting homoallylic alcohols, new approaches aimed at solving the problem of activation of allylic boron and silicon reagents are needed. This Minireview describes a number of recent approaches that have been devised to address this problem.

A series of 1,n-dioxa[n](2,7)pyrenophanes (n = 7-12) with increasingly nonplanar pyrene moieties was synthesized by a 9-10 step sequence starting from 5-hydroxyisophthalic acid. The crystal structure of each member of this series was determined crystallographically. Several spectroscopic properties were found to vary with the extent of the nonplanarity of the pyrene unit. The way in which the distortion from planarity of the pyrene system influences its pi-electron delocalization was investigated by using two quantitative descriptors of aromaticity based on geometry (HOMA) and magnetism (magnetic susceptibility and NICS). Both methods suggest that the aromaticity of the pyrene moiety is diminished only slightly upon increasing the bend angle theta from 0 degrees to 109.2 degrees.

This communication successfully challenges the perception that the additions of allylbonates to aldehydes cannot be catalyzed effectively by added Lewis acids. Using a novel class of isomerically pure, tetrasubstituted 2-alkoxycarbonyl allylboronates (1), we describe that some metals (for example, Sc(OTf)(3) and Cu(OTf)(2)) allow these reagents to add onto aldehydes to yield gamma-lactone products 2 in good yields at temperatures almost 100 degrees C lower than the corresponding uncatalyzed reactions. The large rate enhancement over the uncatalyzed reaction provides a highly improved practical approach to access aldol-like adducts with a stereogenic quaternary carbon center. The crucial role of the 2-alkoxycarbonyl group on allylboronates 1 was demonstrated with control experiments using a model allylboronate lacking such an ester group. Moreover, the stereospecificity observed in the uncatalyzed allylborations is preserved. These observations raise intriguing mechanistic issues such as the suggestion that type I allylmetal behavior is maintained in this unprecedented catalytic reaction manifold.

In spite of their inherent isomerization tendency and low reactivity, 1-alkoxycarbonyl vinylcopper(I) intermediates from the conjugate addition of organocuprates onto acetylenic esters were trapped with very high cis-addition selectivity with iodomethylboronic esters in the presence of HMPA. The resulting isomerically pure 3,3-disubstituted allylboronates react with aldehydes in a highly diastereo- and enantioselective manner, providing alpha-exomethylene gamma-lactones with a stereogenic quaternary beta-carbon center.

Background: Patients with peripheral arterial disease (PAD) are at an increased risk of cardiovascular mortality and morbidity and thus are an excellent group in whom to evaluate the feasibility and the effect of an aggressive multifactorial intervention on atherosclerotic vascular disease risk factors. The Arterial Disease Multiple Intervention Trial (ADMIT) was designed to determine the efficacy, safety, and compliance of an multifactorial therapy on selected atherosclerotic disease risk factors in patients with PAD., Methods: By a 2 x 2 x 2 factorial design, eligible participants (N = 468) were randomly assigned to low-dose warfarin, antioxidant vitamins, and niacin or its corresponding placebo, and followed up for 1 year. All participants were encouraged to use aspirin. Pravastatin was added to the drug regimen for those who needed to reduce LDL cholesterol to recommended levels., Results: Niacin increased HDL cholesterol levels by 30%, with the majority of effect achieved at a dosage of 500 mg twice daily. Warfarin had an anticoagulant effect. The antioxidant vitamins resulted in a significant increase in vitamin E, C, and beta-carotene plasma levels. Overall, compliance was high and few adverse effects were reported., Conclusions: ADMIT demonstrates that it is both feasible and safe to modify multiple atherosclerotic disease risk factors effectively with intensive combination therapy in patients with PAD.

Background: Patients with peripheral arterial disease (PAD) have high rates of cardiovascular morbidity and mortality, including that caused by associated coronary heart disease and cerebrovascular disease. Previous studies have shown that coagulation parameters are altered in PAD and that altered coagulation may play a critical role in the susceptibility to cardiovascular complications in PAD. It is therefore important to assess the effect of secondary prevention measures on coagulation in patients with PAD. The Arterial Disease Multiple Intervention Trial (ADMIT), a multicenter, randomized, placebo-controlled trial, was conducted to determine the feasibility of a combined lipid-modifying, antioxidant, and antithrombotic treatment regimen in patients with PAD. The objective of this study was to assess the effect of the ADMIT interventions on coagulation., Methods: ADMIT participants were randomly assigned to low-dose warfarin, niacin, and antioxidant vitamin cocktail or corresponding placebos in a 2 x 2 x 2 factorial design. Specialized coagulation studies were performed in a subset of 80 ADMIT participants at baseline and after 12 months of treatment., Results: Low-dose warfarin (1 to 4 mg/d) resulted in a significant decrease in factor VIIc (P <.001) and in plasma F1.2 (P =.001). Unexpectedly, niacin treatment also resulted in significant decrease in both fibrinogen (48 mg/dL; P <.001) and F1.2 (P =.04). von Willebrand factor increased after antioxidant vitamin treatment (P =.04)., Conclusions: A regimen of low-dose warfarin effectively modifies coagulation in patients with PAD. Niacin also favorably modifies fibrinogen and plasma F1.2. Niacin, in addition to its lipid effects, modifies abnormal coagulation factors that accompany PAD.