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Soft-tissue ankle injuries are extremely common and frequently present in the emergency department or to the general practitioner. The lateral ligament complex is most commonly affected, usually following an injury with the ankle in an inverted, plantar-flexed position. The diagnosis is usually clinical, and delayed examination and reassessment 3-5 days after injury is recommended as pain and swelling hinder accurate assessment immediately following injury. Applying the Ottawa ankle rules can reduce the number of unnecessary radiographs. Treatment is usually nonoperative with the focus on controlling ankle swelling and pain, and early restoration of ankle movements. Surgical repair of ligaments may be indicated in certain cases, though the role of surgery in the acute setting remains unclear. In the present review, we discuss the anatomy, mechanism of injury, risk factors, clinical presentation, diagnosis, treatment and outcome of soft-tissue ankle injuries as well as consider how such injuries may be prevented. [ABSTRACT FROM AUTHOR]

The aim of this study was to establish how accurately a trained continence nurse could allocate appropriate second-line conservative treatment to women without urodynamic investigations. Depending on the number of patients coming taking up the service, there were between five and 12 nurses operating at any one time. Women aged 40 years and over, of which there were 2421 reporting lower urinary tract symptoms, were randomly allocated to a new nurse-led continence service. Of these women, 450 subsequently underwent urodynamic investigation, before which the nurses documented which second-line conservative treatment would be appropriate. The results showed that of all women with detrusor overactivity, 79.1% were correctly allocated anticholinergic treatment, and 64.8% were allocated pelvic floor exercises (PFE). Of all women with urodynamic stress incontinence, 88.8% were correctly allocated PFE, and 43.4% were allocated anticholinergic therapy. Of all women with mixed incontinence, 44.8% were correctly allocated both PFE and anticholinergic therapy, while 52.1% were allocated only one treatment. This study showed that a trained continence nurse is able to allocate conservative treatment appropriately the majority of women without the need for urodynamic investigation. This indicated that the management of urinary dysfunction by a team of trained, dedicated nurses has the potential to reduce waiting lists for urodynamic investigation, avoid unnecessary investigations and achieve greater patient satisfaction. [ABSTRACT FROM AUTHOR]

The elderly are prone to respiratory infection but the role of disordered immunity is uncertain. Opsonization of bacteria is an important early host defence mechanism required for optimal phagocytosis. There are conflicting reports in the literature as to the ability of the elderly to perform this function and one reason may be the use of in vitro tests in which the `target' microorganism is clinically unrealistic. We have tested the hypothesis that use of a more clinically relevant microorganism Haemophilus influenzae, which commonly infects the respiratory tract of such persons, may detect abnormalities of opsonization in the elderly. Using an in vitro luminol-enhanced chemiluminescence (CL) assay we have compared sera from 45 elderly subjects (age >70 years without known immune deficiency or current infection) with sera from 12 young, healthy subjects, for their capacity to opsonize Staphylococcus aureus (Oxford strain) and H. influenzae (non-capsulated) expressed as percentage CL obtained using pooled normal human serum (PNHS). There was no significant difference (median) between the elderly (95%) and the young (108%) with regard to S. aureus but opsonization of H. influenzae was poor in the elderly (63%) compared with that in the younger group (87%; P= 0002); the sera of 11 elderly subjects having an opsonic capacity less than 30% that of PNHS. We conclude that use of the more clinically relevant microorganism, H. influenzae, appears to differentiate a subgroup of the elderly with reduced serum opsonic capacity. It remains to be determined prospectively whether these individuals are in fact more prone to infection. [ABSTRACT FROM AUTHOR]

The clinical course of a patient with peripartum cardiomyopathy and hyperprolactinaemia is described. Hyperprolactinaemia may be a factor in this patient's heart failure. [ABSTRACT FROM PUBLISHER]

Introduction: We estimated the number of primary total hip and knee replacements (THR and TKR) that will need to be performed up to the year 2060., Methods: We used data from The National Joint Registry for England, Wales, Northern Ireland and the Isle of Man on the volume of primary THRs ( n =94,936) and TKRs ( n =100,547) performed in 2018. We projected future numbers of THR and TKR using a static estimated rate from 2018 applied to population growth forecast data from the UK Office for National Statistics up to 2060., Results: By 2060, THR and TKR volume would increase from 2018 levels by an estimated 37.7% ( n =130,766) and 36.6% ( n =137,341), respectively. For both males and females demand for surgery was also higher for patients aged 70 and over, with older patients having the biggest relative increase in volume over time: 70-79 years (44.6% males, 41.2% females); 80-89 years (112.4% males, 85.6% females); 90 years and older (348.0% males, 198.2% females)., Conclusion: By 2060 demand for hip and knee joint replacement is estimated to increase by almost 40%. Demand will be greatest in older patients (70+ years), which will have significant implications for the health service requiring forward planning given that morbidity and resource use is higher in this population. These issues, coupled with two waves of COVID-19, will impact the ability of health services to deliver timely joint replacement to many patients for a number of years, requiring urgent planning.

Introduction: We assessed the practice of surgeons regarding venous thromboembolism (VTE) chemical prophylaxis for total hip replacement (THR) and total knee replacement (TKR), before and after issuing of updated National Institute for Health and Care Excellence (NICE) guidance in 2018., Methods: A survey, circulated through the British Hip Society and regional trainee networks/collaboratives, was completed by 306 UK surgeons at 187 units. VTE chemical prophylaxis prescribing patterns for surgeons carrying out primary THR ( n =258) and TKR ( n =253) in low-risk patients was assessed after publication of 2018 NICE recommendations. Prescribing patterns before and after the NICE publication were subsequently explored., Results: Following the new guidance, 34% ( n =87) used low-molecular-weight heparin (LMWH) alone, 33% ( n =85) aspirin (commonly preceded by LMWH) and 31% ( n =81) direct oral anticoagulants (DOACs: with/without preceding LMWH) for THR. For TKR, 42% ( n =105) used aspirin (usually monotherapy), 31% ( n =78) LMWH alone and 27% ( n =68) DOAC (with/without preceding LMWH). NICE guidance changed the practice of 34% of hip surgeons and 41% of knee surgeons, with significantly increased use of aspirin preceded by LMWH for THR (before=25% vs after=73%; p <0.001), and aspirin for TKR (before=18% vs after=84%; p <0.001). Significantly more regimens were NICE guidance compliant after the 2018 update for THR (before=85.7% vs after=92.6%; p =0.011) and TKR (before=87.0% vs after=98.8%; p <0.001)., Conclusion: Over one-third of surveyed surgeons changed their VTE chemical prophylaxis in response to 2018 NICE recommendations, with more THR and TKR surgeons now compliant with latest NICE guidance. The major change in practice was an increased use of aspirin for VTE chemical prophylaxis.

Background: The optimum chemical venous thromboembolism (VTE) prophylactic agents following total hip and knee replacement (THR and TKR) remain unknown. NICE recommends multiple agents, including direct oral anticoagulants (DOACs), low-molecular weight heparin (LMWH), and aspirin. We assessed whether VTE prophylaxis affected the risk of VTE and adverse events following primary THR and TKR., Materials and Methods: We reviewed 982 elective primary THRs (59%) and TKRs (41%) at a large tertiary centre during 2018. The primary outcome was any VTE (DVT and/or PE) within 90-days. Secondary outcomes were adverse events within 90-days (major bleeding and wound complications). The association between VTE prophylaxis and outcomes was assessed., Results: The overall prevalence of VTE and adverse events were 2.7% (n = 27) and 15.2% (n = 136) respectively. The most common agents used were DOAC ± LMWH (50.7%, n = 498), followed by aspirin ± LMWH (35.5%, n = 349) and LMWH alone (4.7%, n = 46). The risk of VTE (aspirin ± LMWH = 3.7%, DOAC = 2.0%, LMWH = 2.2%) was not significantly different between agents (p = 0.294). The risk of any adverse event was significantly higher (p < 0.001) with aspirin ± LMWH (16.1%; n = 56) and LMWH (28.3%; n = 13) compared with DOACs ± LMWH (7.0%; n = 35) in TKRs only, there was no differences between agents for adverse events in THRs (p = 0.644)., Conclusions: Choice of thromboprophylaxis did not influence the risk of VTE following primary THR and TKR. DOACs (+/- LMWH) were associated with the lowest risk of adverse events. Large multicentre trials are still needed to assess the efficacy and safety of these agents following THR and TKR., Competing Interests: MW declares fees paid for presentations for the companies DePuy and Heraeus (funds paid to institution for postgraduate teaching), financial support as a principle investigator from Stryker, DePuy, Heraues, JRI and CeramTec and other financial or material support from Stryker, DePuy, Heraues, JRI, CeramTec. They also declare royalties from Taylor and Francis for editing of Orthopaedic textbook and the following committee appointments: Associate Editor of Hip International, Editorial board Bone Joint Journal EFORT Basic Science task force committee member, British Orthopaedic Association Research Committee, British Hip Society Research Committee. GM declares medicolegal work for Leigh Day and financial support from the following as principle investigator: Surgical Research Fellowship awarded from The Royal College of Surgeons of England, Clinical Research Fellowship awarded from Arthritis Research UK, Research Grants from The Orthopaedics Trust, and The Royal Orthopaedic Hospital Hip Fund and The Academy of Medical Sciences Starter Grants for Clinical Lecturers. Both FT and DY have no conflicting interests to declare., (© 2021 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. All rights reserved.)